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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800881
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:50:29 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211020160657
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:DUNA JOSON (AGSALOG)FACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 5DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Michelle Meeks - staffTIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Michelle Meeks - staff.

On 10/21/21, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file, Suspected Abuse Report (SOC 341) submitted by facility on 10/15/2021, pictures, and interviews conducted on 11/9, 11/18, 11/19, 12/14, and 12/18/21; LPA learned that client C1 had an unexplained bruising while in care. According to staff interviews, no one had seen client C1 left arm bruising until day program contacted facility regarding it after client C1 took jacket off. Per pictures bruise was already blackish/green when day program observed client C1 bruise. (see documentation, pictures, LIC 809-D)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 3
Control Number 21-AS-20211020160657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 12/22/2021
NARRATIVE
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 Based on observation and interviews, client C1 sustained an unexplained bruising while in care.

According with complaint allegation "Resident sustained unexplained bruising while in care..” there was related observations made during visit. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20211020160657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
85075.4
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85075.4 Observation of the client. This requirement isn't met as evidenced by: Based on interivews & records review facility staff didn't comply w/this section for 1of1 client which poses an immediate Health,
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Facility agrees to conduct staff training regarding mandated reporting & C1's careplan. Proof of staff training w/participants signature, trainer signature, what was covered, and date of training
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Safety risk to clients in care.Client C1 had an unexplained bruise on her top left arm that wasn't observed by facility. Facility learned about bruising after day program informed facility that bruise was obs. after C1 took jacked off.
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to be submitted to CCL by 1/5/21. Facility to submit self certification that clients will be supervised & kept safe by POC date 12/23/21.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3