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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 176801307
Report Date: 08/27/2024
Date Signed: 08/27/2024 01:02:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240802094619
FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY:6CENSUS: 6DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mariah Uden, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not treat residents with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Mariah Uden, Administrator.

During the course of this investigation LPA conducted interviews, made observations, and obtained documents.

Staff did not treat residents with dignity and respect- Complainant alleges there is a sign hanging on the interior front door which is a notice to clients advising them not to disturb the overnight staff or open the door, or the staff will take longer to get up. On 8/8/24 LPA conducted a visit of the facility and observed the signage. LPA’s interview with the administrator revealed, the sign was put up because they have had different clients who come through who can get up early like 5am and try to go out and smoke but this will set door alarms off, waking everyone.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240802094619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
VISIT DATE: 08/27/2024
NARRATIVE
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Continued from LIC9099-

LPA observed Administrator take the sign down. Investigation revealed the facility staff did not treat residents with dignity and respect by posting a sign of threat of a punitive nature for leaving facility earlier then a specified time. The facility is 24/7 and staff should be available if clients need assistance at any time, or they want to go outside. Due to observations & interviews allegation Staff did not treat residents with dignity and respect is Substantiated.
A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240802094619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
80072(a)(3)
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80072(a)(3) Personal Rights (a) ..each client shall have personal rights which include, but are not limited to, the following: (3)To be free from corporal or unusual punishment… intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions,….*This requirement was not met as evidenced by:
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POC: Administrator immediately removed signage from the facility on 8/8/2024.

Citation cleared at visit
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Based on interviews conducted and observations, Administrator did not ensure the regulation above due to sign posted was to intimidate clients from opening doors prior to 7am or staff will take longer to get up, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240802094619

FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY:6CENSUS: DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure that medications were properly stored
Staff did not provide adequate food service
Staff did not provide a safe and comfortable environment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Mariah Uden, Administrator.

During the course of this investigation LPA conducted interviews, made observations, and obtained documents.

Staff did not ensure that medications were properly stored – Complainant alleges medications were not in locked storage and were on the counter in the office. LPA’s follow up interview with complainant informed the office door was open, but a staff member was there. On 8/8/2024 at approximately 9:30 am LPA observed Administrator making breakfast and putting morning medications together, medications were out in the office and then put away 15 minutes later.
Continue on LI9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240802094619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
VISIT DATE: 08/27/2024
NARRATIVE
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Continued from LIC9099-A

Interview with Administrator revealed after each time medications are given, usually with meals, they are then put away in locked cabinet and the office door is locked. LPA has not observed medications not locked up without a staff member present. Therefore, allegation Staff did not ensure that medications were properly stored is found to be Unsubstantiated.

Staff did not provide adequate food service- Complainant alleges the facilities food supply appears lacking and there was little to no fresh vegetables and no fresh fruit in sight. On 8/8/2024 LPA observed facility to have, per regulation 85076(d)(1): supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days for the current number of clients in care (pics). LPA also observed frozen & canned fruits as well as vegetables and was informed by administrator Thursday is shopping day. On 8/8/2024 at 12:25pm LPA also observed lunch being eaten by the 3 clients remaining at the facility which consisted of; raspberry tea, homemade rigatoni & green beans with a small tangerine & vanilla pudding cups. 2 clients also had a slice of bread with butter on it. Therefore, allegation Staff did not provide adequate food service is found to be Unsubstantiated.



Staff did not provide a safe and comfortable environment – Complainant alleges a client’s room has open containers of detergent, shampoos, and hygiene products; the facility does not have an evacuation plan in plain sight, however, it could be posted in the office, which is inaccessible to clients; the facility is dark, with the curtains closed. LPA obtained Physician’s reports & current care plans for all clients in care, and none have behaviors indicating they would be in danger if they had access to detergent, shampoo, or hygiene products. LPA observed facility evacuation plan in office on day of visit. Administrator informed, there is a map posted next to the disaster plan, but clients periodically will take them down and sometimes replace with their own artwork which apparently happened again. Administrator put a new map up and provided LPA a copy. -Interview with Administrator revealed most of the curtains are kept closed during the summer to keep some of the heat out. On 8/8/20204 LPA was at facility from approximately 9:30am until 1:45pm and facility was a comfortable temperature and all clients observed appeared to be clean & in good spirits. Therefore, allegation Staff did not provide a safe and comfortable environment is found to be Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5