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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210110627
Report Date: 05/24/2024
Date Signed: 05/24/2024 02:17:20 PM

Unsubstantiated


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
02/01/2024 and conducted by Evaluator Helena Rummonds
COMPLAINT CONTROL NUMBER: 21-AS-20240201224108
FACILITY NAME:CEDARS BROWN DRIVEFACILITY NUMBER:
210110627
ADMINISTRATOR:LEPE, MARIAFACILITY TYPE:
735
ADDRESS:6 BROWN DRIVETELEPHONE:
(415) 892-1421
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:6CENSUS: 4DATE:
05/24/2024
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator, Maria LepeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Client sustained unexplained injury while in care
Staff did not properly report an incident involving a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 12:25PM to deliver findings regarding the above allegations. LPA was greeted by Administrator, Maria Lepe. LPA and Administrator discussed the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents.

Complaint alleges that a client sustained an unexplained injury while in care, but the cause was unknown. The client suffers from numerous skin issues that are generally slow healing due to the client’s Diabetes. Information obtained from interviews did not reveal an event or situation that explained the injury.

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

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
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 2
Control Number 21-AS-20240201224108
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: CEDARS BROWN DRIVE
FACILITY NUMBER: 210110627
VISIT DATE: 05/24/2024
NARRATIVE
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Continued from LIC 9099

Complaint alleges that staff did not properly report an incident involving a client. Interviews conducted revealed that there is a client who has a history of withholding medical information, as they generally are private with personal information. Interviews revealed that staff were unaware of any additional medical attention that was necessary.

Based on interviews conducted and observations made, and while the allegation may be 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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2