216800503-10-23-2024-21-AS-VBEI-DAHPXH-20241029114221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800503
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:35:47 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
07/11/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240711104212

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: 3	DATE:	10/23/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee/Administrator, Pilar De Olave		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Questionable death

INVESTIGATION FINDINGS:

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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint regarding the above allegations and met with Licensee/Administrator, Pilar De Olave. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations.

The following allegations were investigated, “Staff handled resident in a rough manner,” and “Questionable death.” Complainant alleged that facility staff roughly placed Resident 1 (R1) on the toilet causing them to hit their head and lose consciousness. Complainant stated that the Fire Department was contacted while R1 was placed in bed and that R1 passed away 10 minutes later. The Department conducted interviews with staff and involved parties. Staff interviews conducted denied that the allegations occurred and stated that residents were not treated in a rude or rough manner.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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-20240711104212

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: SHALOM HOUSE	FACILITY NUMBER: 216800503
	VISIT DATE: 10/23/2024

NARRATIVE

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Continued from LIC9099

Interviews conducted with involved parties stated that R1 was not observed to have any visible injuries and did not suspect that abuse occurred at the facility.

The Department contacted the City of San Rafael Fire Department and Marin County Fire Department for records related to R1 and the alleged incident. Both departments stated that there are no records available or on file.

Review of R1’s documents indicated that they were admitted to Hospice on 10/28/2022 for unspecified sequelae of cerebral infarction. R1’s death certificate stated that they passed from unspecified sequelae of cerebral infarction/cerebral infarction and that no other significant conditions contributed to their death.

Based on interviews conducted, documents reviewed, and observations made, the Department was unable to determine if a violation of Title 22 Regulations has occurred. Therefore, the allegations are Unsubstantiated.

A finding that the 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.

No Deficiencies Cited during visit.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC9099 (FAS) - (06/04)

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