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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800881
Report Date: 01/23/2023
Date Signed: 01/23/2023 01:42:45 PM

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
11/29/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221129154209
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:
01/23/2023
UNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Savannah Finley (DSP)TIME COMPLETED:
01:57 PM
ALLEGATION(S):
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Staff is without a first aid certification.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with staff Savannah Finley. Program Manager Andrea Jackson was not able to come to the facility, but she gave authorization for staff to sign the report.

It was alleged that staff (S1) is without a first aid certification. It was reported that S1 was working at this facility without required first aid certification. Based on records review of facility staff files provided by Administrator, S1 was hired on 11/16/22 to provide care and supervision to clients in care and was terminated on 11/24/22. However, it was revealed a lack of proof of current required First Aid certification for S1. Based on observations, records reviewed, and interviews conducted with Administrator, the facility did not ensure S1 received required first aid certification prior to provide care and supervision to clients in care as stated per regulation.
Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
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 5
Control Number 21-AS-20221129154209
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: 01/23/2023
NARRATIVE
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Continued from LIC9099...

Also, LPA was informed by current Administrator that their current job title is Quality Assurance Manager, and they are not present on the premises the number of hours necessary to manage and administer the facility in compliance per regulation. A technical violation will be issued under a case management visit to address the appointment of an Administrator for this facility. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with Program Manager over the phone and staff signed the report whose signature below confirms receipt of report.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20221129154209
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: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
80075(f)
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80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
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Program Manager agreed to review all staff training records to ensure that all staff have current required first aid certification. Program Manager agreed to submit a self-certification LIC9098 ensuring that all staff have required first aid certification on file to clear the citation by POC due date.
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Based on records reviewed and interviews with Administrator, the facility did not ensure that S1 received required first aid certification prior to provide care and supervision to clients in care as stated per regulation which poses a potential health, safety, and personal rights risk to clients in care.
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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: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5