216800652-2-7-2023-21-AS-KMOA-CP52CX-20230216161729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800652
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:34:41 PM

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
11/29/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20221129150227

FACILITY NAME:	BELLE HOUSE		FACILITY NUMBER:	216800652
ADMINISTRATOR:	SMITH, SHAQUILA		FACILITY TYPE:	735
ADDRESS:	865 BELLE AVENUE		TELEPHONE:	(415) 457-9632
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	6	CENSUS: 6	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Assistant Manager, Yvette Morgan		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff not ensuring resident is properly clothed
Staff yelled at resident
Staff smoking marijuana on the premises
Staff did not ensure resident is provided clean clothing

INVESTIGATION FINDINGS:

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At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for the Complaint Investigation regarding the above allegations above and met with Assistant Manager, Yvette Morgan.

During the course of the investigation, LPA Felias requested and reviewed documents, made observations, and conducted interviews. There is an allegation that staff did not ensure resident is properly clothed and that staff did not ensure resident is provided with clean clothing. Per information provided to LPA, there is a concern that residents are in dirty clothing and do not wear coats while outside in the cold. During visit conducted on 12/1/2022 and 2/7/2023, LPA observed that residents in the home were wearing clean clothes that were appropriate for the weather. Interviews conducted stated that residents are able to change their clothes without assistance, or with verbal reminders and prompting.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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-20221129150227

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: BELLE HOUSE	FACILITY NUMBER: 216800652
	VISIT DATE: 02/07/2023

NARRATIVE

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Continued from LIC9099

Review of Resident 1's (R1) Individual Day Program Service Plan, dated 9/20/2021, stated that the facility assists R1 in completing their hygiene tasks such as showering and dressing appropriately for the day by providing instruction. Review of R1’s quarterly report, dated 7/17/2022, stated that R1 has been successful in completing hygiene needs with verbal prompting. R1’s behavior data forms dated November 2022, indicated that staff were assisting R1 with their hygiene needs. Interviews also stated that laundry is done for the residents at least two to three times per week and as needed for incontinence care. During visits conducted 12/1/2022 and 2/07/2023, LPA observed staff member and R1 doing laundry together as an activity. Based on documents reviewed, interviews conducted, and observations made, the allegations that staff did not ensure resident is properly clothed and staff did not ensure resident is provided with clean clothing is Unsubstantiated.

There is an allegation that staff yelled at resident and staff smoked marijuana on the premises. Per information provided to the LPA, staff have been observed to be smoking marijuana on the premises and that there was yelling heard from inside the house. Review of Facility’s Drug and Alcohol Policy and Facility’s Rules of Conduct stated that employees are prohibited from being under the influence while on duty or performing facility business, and that drugs and alcohol must not be brought onto the property. Interviews conducted indicated that there have not been any staff member observed to be under the influence of drugs and/or alcohol, but some of the clients’ family members do smoke marijuana when visiting their loved ones. Interviews conducted also indicated that there have been no observations of staff yelling at residents within the past year. LPA was informed that a former staff member was terminated for yelling at residents and was no longer working for the facility. Based on interviews conducted and document review, the allegations that staff yelled at resident and staff smoked marijuana on the premises are Unsubstantiated.

A finding that the Complaint 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, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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