216800503-2-17-2023-21-AS-KMOA-CPAMRC-20230222085005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800503
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:34:40 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
01/10/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230110160945

FACILITY NAME:	SHALOM HOUSE		FACILITY NUMBER:	216800503
ADMINISTRATOR:	MARIA DEL PILAR DE OLAVE		FACILITY TYPE:	740
ADDRESS:	566 WAKEROBIN LANE		TELEPHONE:	(415) 491-0604
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	5	CENSUS: 4	DATE:	02/17/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Pilar De Olave		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Insufficent Staffing

INVESTIGATION FINDINGS:

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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, Pilar De Olave.

During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation of insufficent staffing. Record review indicated that there are two staff members scheduled at the facility to provide care. During visits conducted on 1/19/2023 and 2/17/2023, LPA observed two staff members at the facility. On 1/19/2023, LPA observed residents participating in activities such as looking at photographs together or listening to music. During visit on 2/17/2023, residents were observed to be in clean clothing and were well groomed. Residents were served breakfast and were assisted with their care needs appropriately. The facility was clean and at a comfortable temperature. Based on records reviewed, interviews conducted, and observations made, the LPA is unable to determine if there is insufficient staffing at the facility. Therefore, this allegation is Unsubstantiated.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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Control Number 21-AS-20230110160945

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: SHALOM HOUSE	FACILITY NUMBER: 216800503
	VISIT DATE: 02/17/2023

NARRATIVE

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Continued from LIC9099

A finding that the Complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No Deficiencies Cited during visit.

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

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

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