<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800881
Report Date: 06/19/2024
Date Signed: 06/19/2024 02:59:18 PM

Substantiated


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
03/21/2024 and conducted by Evaluator Helena Rummonds
COMPLAINT CONTROL NUMBER: 21-AS-20240321132852
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:JACKSON, ANDREAFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 525-1082
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 5DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Manager of Program Operations, Kayla HotchkissTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff allowed client in care to leave the facility unassisted
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Manager of Program Operations, Kayla Hotchiss arrived shortly after. LPA and Manager of Program Operations discussed the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents.

Complaint alleges that staff allowed client in care to leave the facility unassisted. LPA received an incident report on 03/11/2024 confirming that Client 1 (C1) eloped into the community on 03/10/2024. Interviews conducted revealed that Staff 1 (S1) and C1 were in the backyard swinging on the bench swing. S1 asked C1 if they would like to go for a walk.

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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
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
03/21/2024 and conducted by Evaluator Helena Rummonds
COMPLAINT CONTROL NUMBER: 21-AS-20240321132852

FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:JACKSON, ANDREAFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 525-1082
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 5DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Manager of Program Operations, Kayla HotchkissTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not call seek timely medical attention for client in care
Staff failed to intervene when client was being force fed by another client
Staff does not ensure toiletries are available to clients in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Manager of Program Operations, Kayla Hotchkiss arrived shortly after. LPA and Manager of Program Operations discussed the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents.

Complaint alleges that staff did not seek timely medical attention for client in care. Interviews conducted revealed that staff noticed Client 1 (C1) might need medical attention and contacted C1s responsible party to inform them that the facility would be taking C1 to the hospital. C1s responsible party informed the facility that they would take C1 to the hospital. Responsible party arrived at the facility and transported C1.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240321132852
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 06/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 9099

Complaint alleges that staff failed to intervene when client was being force fed by another client. Based on interviews conducted, facility staff have never seen another client force feed another client, and staff confirmed that clients generally do not want to share their food with other clients in care.

Complaint alleges that staff does not ensure toiletries are available to clients in care. Interviews conducted revealed that there are multiple clients in the facility that shove toilet paper and paper towels into the toilet, causing plumbing issues. Facility staff had a system in which anytime a client needed toiletries, staff would give it to clients as needed. Based on observation and interview, facility has implemented a new system that allows for toiletries to be accessible at all times.

Based on interviews conducted, documents reviewed, and observations made, and while the allegations may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240321132852
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 06/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 9099

S1 went into the house to get ready to leave for the walk and C1 was gone. Based on interviews conducted, facility staff are aware that C1s responsible party has a tracker on C1s phone, and responsible party was able to provide C1s location to facility staff. C1 was found at the market down the street with a bag of groceries.

Based on interviews conducted, documents reviewed, and record review, 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, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240321132852
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2024
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

1
2
3
4
5
6
7
Facility agrees to conduct staff training regarding elopments & C1 careplan. Proof of staff training w/participants signature, trainer signature, what was covered, & date of training to be submitted to CCL by 07/10/2024.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above by allowing client to elope into the community unassisted.
8
9
10
11
12
13
14
Facility to submit self certification that clients will be supervised & kept safe by POC date 06/20/2024.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5