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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210104607
Report Date: 04/25/2024
Date Signed: 04/25/2024 10:32:21 AM

Unfounded


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
04/11/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240411104534
FACILITY NAME:DANIEL REST HOMEFACILITY NUMBER:
210104607
ADMINISTRATOR:DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:28 ROOSEVELT AVENUETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 4DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Silvana DanielTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility is not meeting resident's care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included the review of documents; taking of witness statements; site visit to the facility. The following determinations are made: Follow-up interview with the Complainant indicates that there was no intent to lodge a complaint against the facility and that the referral was made in hopes of obtaining assistance in locating a placement for R1 in a higher level of care; The Complainant and the Administrator indicate that the Administrator was not properly informed by the placing agency of the extend of care required for R1 and that financial issues precluded R1's placement in skilled nursing; The Physician's Assessment Report(LIC 602) provided to the Administrator does not accurately describe R1's behaviors; The Complainant and the Nurse Case Manager familiar with R1's care at the facility state that the facility provided excellent care to R1 and made every effort allowed under the Administrator's license to meet the care needs of R1. Based on statements and records, we have found the complaint to be UNFOUNDED, meaning that the allegation is false and without a reasonable basis. The complaint is DISMISSED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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