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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800847
Report Date: 07/30/2026
Date Signed: 07/30/2026 12:55:17 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
06/08/2026 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20260608145615
FACILITY NAME:CEDARS WALTER HOUSEFACILITY NUMBER:
216800847
ADMINISTRATOR:KEMMETER, FRANKFACILITY TYPE:
735
ADDRESS:1842 NOVATO BLVDTELEPHONE:
(415) 892-1073
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:6CENSUS: 5DATE:
07/30/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Frank KemmeterTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not obtain timely medical care for a resident after a fall
INVESTIGATION FINDINGS:
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On 07/30/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Administrator, Frank Kemmeter. During the course of the investigation, LPA reviewed records, conducted interviews, and made observations.

Compliant alleges staff did not obtain timely medical care for a resident after a fall. Reporting Party (RP) states client (C1) had a fall in the facility in early 2026 and staff did not obtain medical care for C1 after the fall. RP states that C1 can no longer walk. Interview with Administrator states that C1 did have a fall earlier in the year 2026 but not at the facility, C1 had a fall at their day program in March 2026. Administrator states C1 has always had mobility issues where C1 would suddenly lose their balance and would sometimes use the walls in the hallway as support when walking. Record review shows C1s day program submitted a Special Incident Report (SIR) to Community Care Licensing (CCL) on 03/06/2026 indicating C1 had a fall on 03/05/2026. C1s progress notes show that following the fall, the facility took C1 to see their physician on 03/19/2026 for a follow up appointment regarding C1s fall.

continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
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 2
Control Number 21-AS-20260608145615
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 WALTER HOUSE
FACILITY NUMBER: 216800847
VISIT DATE: 07/30/2026
NARRATIVE
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Notes from 3/19/2026 show X-rays were taken to check for a compression fracture after C1 was experiencing acute low back pain and impaired mobility after the fall. On 3/23/2026 C1 was seen by their physician and review of C1s x-rays showed that C1 had a kidney stone where C1 was having pain. On 4/23/2026 C1 was seen by a new physician for a follow up appointment. On 5/19/2026 C1 was seen by another physician to follow up on C1s pain and mobility issues and orders of MRIs were scheduled for 6/18/2026 and 6/30/2026. It should be noted that C1 moved to another facility on 06/04/2026.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2