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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210109691
Report Date: 01/30/2026
Date Signed: 01/30/2026 12:41:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/17/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20251017163505
FACILITY NAME:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR:JOHN AHRENSFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:10CENSUS: 9DATE:
01/30/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Staff Members, Anders Helmersson and Mark SaltingTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee is not preventing resident from being verbally abused while in care
INVESTIGATION FINDINGS:
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At approximately 8:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations and met with Staff Members, Anders Helmersson and Mark Salting. Program Director, John Ahrens, arrived during visit at approximately 9:30AM and left at approximately 10:45AM. Assistant Program Director, Suhay Rivas, was available by telephone. Program Director and Assistant Program Director gave permission for Staff Member, Mark Salting, to sign in their place.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Licensee is not preventing resident from being verbally abused while in care." Complaint alleged that Client 1 (C1) has been verbally berated and made to feel less than by facility staff.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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-20251017163505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: D STREET RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109691
VISIT DATE: 01/30/2026
NARRATIVE
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Continued from LIC9099

Interviews conducted with Assistant Program Director and Team Leader revealed that Staff Member 1 (S1) received disciplinary action regarding their professionalism and inappropriate communication with clients.
Review of facility documents showed that S1 received a correction action form on 01/15/2025.

Based on interviews conducted and record review, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Staff Member. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20251017163505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: D STREET RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2026
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights:(a)...each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by: based on record review and interviews,
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Licensee to submit proof of training reviewing policy on workplace professionalism and communciating appropriately with clients. Proof of training to be submitted by POC due date of 2/10/2026 for review and approval.
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Licensee did not comply with the section cited above. S1 was found to have been communicating inappropriately with C1. This is a potential health and safety risk to clients 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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/17/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20251017163505

FACILITY NAME:D STREET RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109691
ADMINISTRATOR:JOHN AHRENSFACILITY TYPE:
735
ADDRESS:527 D STREETTELEPHONE:
(415) 454-9920
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:10CENSUS: 9DATE:
01/30/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Staff Members, Anders Helmersson and Mark SaltingTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee is not ensuring that resident is administered their medications while in care
INVESTIGATION FINDINGS:
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At approximately 8:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Staff Members, Anders Helmersson and Mark Salting. Program Director, John Ahrens, arrived during visit at approximately 9:30AM and left at approximately 10:45AM. Assistant Program Director, Suhay Rivas, was available by telephone. Program Director and Assistant Program Director gave permission for Staff Member, Mark Salting, to sign in their place.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated,“Licensee is not ensuring that resident is administered their medications while in care.” Complaint alleged that the facility was withholding Client 1's (C1's) pain medication."

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20251017163505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: D STREET RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109691
VISIT DATE: 01/30/2026
NARRATIVE
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Continued from LIC9099

Interviews conducted with Assistant Program Director and Team Leader revealed that C1 has PRN or “as needed” pain medication. Per interviews, C1 has PRN pain medication that is on a medication schedule per physician orders. C1 will get upset when told that they have to wait to receive the next dose of pain medication at the appropriately scheduled time and will request for the time to be changed so they can receive their next dose earlier than allowed. Email correspondence between facility, C1’s case management team, and psychiatrist, indicated that all entities were aware of C1’s behaviors and requests and were actively working on educating C1 on appropriate PRN “as needed” medication use.

Interview conducted with C1 indicated that they have been receiving their PRN pain medications when requested.

Based on record review and interviews conducted, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Staff Member. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5