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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210109022
Report Date: 07/03/2025
Date Signed: 07/03/2025 10:12:08 AM

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
04/02/2025 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250402140146
FACILITY NAME:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR:JOHN AHRENSFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:15CENSUS: 15DATE:
07/03/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mental Health Counselor, Debra SmithTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff prohibit residents from coming and going from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Mental Health Counselor, Debora Smith. Staff contacted Assistant Program Director Suhay Rivas for approval to sign for documents today. During the course of this investigation statements were taken, observations made, and documents obtained and reviewed.

Staff prohibit residents from coming and going from the facility- Complainant alleges "the team leader/house manager, Jacquie Burns is prohibiting residents/clients from accessing the property or neighboring properties if they return from the community with any indication of being under the influence of drugs or alcohol. Interview with House Manager revealed “If someone comes back and are under the influence or it is believed they are, of marijuana, I will ask them to leave and come back in an hour. This occurred a month ago, March 2025. I asked the client to leave and come back an hour later.”
Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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 5
Control Number 21-AS-20250402140146
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: 07/03/2025
NARRATIVE
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Continued from LIC9099

Personal Rights regulation 80072(a)(3) 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: or withholding of shelter. Based on interviews conducted, staff did prohibit client from returning to facility, therefore the preponderance of evidence standard has been met, the above allegation is Substantiated.

A finding that complaint allegations are substantiated means that the allegation is valid because the preponderance of the evidence standard has been met, therefore the allegation is SUBSTANTIATED.

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: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250402140146
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2025
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, or withholding of shelter,….*This requirement was not met as evidenced by:
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 Program Director indicated House Manager no longer works at facility. Staff to be retraining on regulation 80072 Personal Rights, have all staff sign,date,etc… return to CCL by 7/11/2025 to clear citation.
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Based on interviews conducted, Program Director did not ensure the regulation above was followed as House Manager stated they asked a client to leave and come back an hour later, 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: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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
04/02/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250402140146

FACILITY NAME:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR:JOHN AHRENSFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:15CENSUS: 15DATE:
07/03/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Mental Health Counselor, Debora SmithTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff do not provide adequate food service for residents
Staff do not allow clients to select the type of treatment they receive
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Mental Health Counselor, Debora Smith. Staff contacted Assistant Program Director Suhay Rivas for approval to sign for documents today. During the course of this investigation statements were taken, observations made, and documents obtained and reviewed.

Staff do not provide adequate food service for residents- Complainant alleges certain foods are being restricted within the house, limiting residents' choices and autonomy. House manager informed: Protein bars are kept locked up, but all the client needs to do is ask for one, or they will be hoarded by some clients and others won't get any. Most all clients have EBT cards, the facility help set up. There are 3 meals provided per day with snacks available (fruit, granola bars, chips, etc.) some go and make their own food. There is a client fridge food they buy they can store it in.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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-20250402140146
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: 07/03/2025
NARRATIVE
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Continue from LIC9099-A

During 4/10/2025 visit LPA observed a bowl of fresh fruit on dining room table along with a large supply of condiments, 2 refrigerator /freezers full of fresh & perishable foods, along with non-perishable foods in cupboards. Three different containers of Cereal at kitchen window to dining room for clients to get themselves. When LPA was leaving, at the beginning of lunch time, hot dogs in buns were being served to those who were ready. Interviews with clients revealed they can eat anything except those with medical conditions are restricted, as with diabetes no sugar, although they have no/low sugar substitutes. There was not sufficient information obtained during investigation to support a violation occurred. Therefore, the allegation Staff do not provide adequate food service for residents is UNSUBSTANTIATED

Staff do not allow clients to select the type of treatment they receive – Complainant alleges clients struggling with marijuana use are being mandated to attend online MA/AA meetings, which may not be suitable for everyone. Interview with house manager informed meetings for AA/MA (Marijuana Anonymous) are not forced upon anyone. We have 1 client who is marijuana dependent, and that client says, the meetings sometimes help. Sometimes they don't want to attend the MA meetings, and they don’t have to. LPA interview with 2 out of 3 clients and 2 staff contradict allegation, indicating they are not forced to attend any specific meetings. Per investigation there was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff do not allow clients to select the type of treatment they receive is 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: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5