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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800881
Report Date: 03/25/2022
Date Signed: 03/25/2022 09:30:57 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, 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
12/29/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211229150035
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:TOOTLE, MICHELLEFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 5DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jayla Rush - Program ManagerTIME COMPLETED:
09:28 AM
ALLEGATION(S):
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Resident sustained unexplained injury 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 Jayla Rush - Program Manager.

On December 30, 2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with staff S1, documentation reviewed including incident report submitted by facility, and staff interviews, LPA learned that client C1 on “December 23, 2021 was observed at 5:45 AM to be in bed and when asked to get up for a shower started making noises and pointed to foot…‘Client C1’ left foot had three red sores near the bone on the inner side of ankle, the surrounding skin was discolored and ankle looked slightly swollen.” (see pictures, SIR)
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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-20211229150035
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 03/25/2022
NARRATIVE
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Client C1 was unable to stand up – physician’s report (LIC 602) dated January 11, 2021 stated that client C1 is ambulatory (copy on file), 911 was contacted and client C1 was taken to the ER. At ER x-ray confirmed that client C1 had fractured left ankle and needed surgery. (see copy of SIR) Client C1 was immediately admitted to the hospital. Per staff interviews, facility did not observe any fall or other signs that she was injury. Staff S2 stated that day program had been contacted and had no knowledge of fall or client getting hurt, and bus company had not report any falls. Facility has overnight staff give clients a shower in the mornings, however; there were no observation of injury before the morning of December 23, 2021. Based on statements from staff and documentation provided and reviewed, facility staff can’t explain the sustained injury that client C1 ended with a fractured and need of surgery. (see LIC 809-D)

Department will be requesting an office meting on April 5, 2022 at 13:00 hour at 1450 Neotomas Ave, suite 100, Santa Rosa; to address multiple unexplained injuries to clients in care. Reference complaints # 21-AS-20210414135710 April, 2021; # 21-AS-20211020160657 October, 2021; and # 21-AS-20211229150035 12/2021.

Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months. Today's assessment of $250.00 is for the period of 12/22/2021 through 3/25/2022 - Title 22 Regulations # 85075.4

*****Total Civil Penalties issued today in the amount of $250.00.

According with complaint allegation " Resident sustained unexplained injury while in care.” there were related observations made during visit. Based on LPAs' 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20211229150035
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
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 potential Health,safety
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Facility agrees to ensure that all clients will be observed for any change of condition. Licensee to submit a program plan on how staff will be checking on clients during their shift to ensure that any change of condition might be
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Personal rights risk to clients in care.Client C1 had unexplained broken ankle wasn't obs. by facility until morning of 12/23/21. C1's ankle was broken,bruised, & had a wound.ER determinaded that C1 needed a surgery.
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observed immediately and care needed will be provided to CCL by April 8, 2022 to avoid civil penalties. In addition a self certification by 3/26/22 that clients are being checked for any injury daily.
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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: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
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