210109022-4-10-2025-21-AS-BMOS-DFSQ2C-20250416114654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210109022
Report Date: 04/10/2025
Date Signed: 04/10/2025 11:39:30 AM

Unsubstantiated

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
04/09/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250409111125

FACILITY NAME:	NOVATO RESIDENTIAL SUPPORT SERVICES		FACILITY NUMBER:	210109022
ADMINISTRATOR:	JOHN AHRENS		FACILITY TYPE:	735
ADDRESS:	1333 SEVENTH STREET		TELEPHONE:	(415) 897-7195
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	15	CENSUS: 14	DATE:	04/10/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jacquie Burns, Team Leader		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee does not ensure staff are properly trained to administer medications to residents
Facility is pre-pouring medications

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and subsequently, delivered findings regarding the allegations listed above. LPA met with Team Leader Jacquie Burns.

During investigation LPA made observations, reviewed documents and conducted interviews.
Complainant alleges staff are not properly trained to administer medications to residents- LPA observed Team leader conduct process of medication passing and observed training/which includes shadowing for 2 days. LPA was able to review staff medication management trainings conducted in relias for 5 out of 7 staff that provide medications to clients. Facility is following their Program Plan with training. Medication passing process is conducted when a client comes to the centrally stored medication room and requests their medications (which are passed out up to 4 times per day depending on the doctor’s prescription orders).
Continue on LI9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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 2

Control Number 21-AS-20250409111125

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: NOVATO RESIDENTIAL SUPPORT SERVICES	FACILITY NUMBER: 210109022
	VISIT DATE: 04/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff will pull up the client name on the computer of medication instruction, take out the medications from the individual client container (some in pre-packaged rolls-envelopes, some in other containers) from a locked cabinet, put the medications in a plastic cup and then count out again in front of client to confirm appropriate medications, then reconcile. Facility does not pour medications until a client is at the medroom door as it could get very confusing. The was not sufficient information obtained to support a violation occurred. Therefore, allegations Licensee does not ensure staff are properly trained to administer medications to residents & Facility is pre-pouring medications if found to be Unsubstantiated.

Although the allegations may be true, based upon the review of documents, observations made and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2