216800881-10-26-2023-21-AS-BMOS-CX6TSR-20231101145936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800881
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:54:42 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
10/20/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231020084117

FACILITY NAME:	SAN LUIS HOUSE		FACILITY NUMBER:	216800881
ADMINISTRATOR:	TOOTLE, MICHELLE		FACILITY TYPE:	735
ADDRESS:	396 SAN LUIS WAY		TELEPHONE:	(415) 897-5716
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	6	CENSUS: 6	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:			TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Client sustained unexplained injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above. LPA was greeted by Veronica Samuel, House Assistant Manager who contacted Administrator Andrea Jackson who arrived shortly after with Kayla Hotchkiss, Manager of Program and Operation.

During investigation LPA reviewed documents, made observations, and conducted interviews.

Client sustained unexplained injury - reporting party reported an unexplained injury of the eye. Reporting party indicates there is bruising of the eye although no other signs of trauma observed.
The Regional Office received a self-reporting incident report on 10/23/2023 indicating that the client was observed on the morning of 10/15/2023 having eye slightly discolored and irritated, was administered allergy medication and medication for irritated skin.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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-20231020084117

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: 10/26/2023

NARRATIVE

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On the following morning, 10/16/2023 staff observed discoloration of eye got darker, and then on 10/17/2023 the area under the client’s eye was bruised. Client had standing doctor’s appointment on 10/20/2023 but facility decided to take client to clinic on 10/18/2023 to be assessed, where doctor could not identify the cause of the bruise. LPA was unable to obtain any further information from complainant and or co-complainant after multiple calls to both.

Based on information received, there was an explanation for the irritation and bruising as client has a history of rubbing eyes and even poking at times due to allergies and eczema. LPA reviewed records and conducted interviews with staff (S1 & S2) and Administrator, confirming history of behavior. It is not necessarily unexplained that client sustained unexplained injury as client has a history of allergies causing irritation of the eyes therefore the allegation is Unsubstantiated.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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