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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801993
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:20:06 PM

Unsubstantiated


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
08/16/2024 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20240816144447
FACILITY NAME:CICADA-MILL VALLEYFACILITY NUMBER:
216801993
ADMINISTRATOR:NOEL CAMATOGFACILITY TYPE:
735
ADDRESS:309 ENTERPRISE CONCOURSETELEPHONE:
(415) 888-3880
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY:6CENSUS: DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Noel CamatogTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulting in severe malnutrition
Neglect/Lack of supervision resulting in unexplained pressure wounds/bruises
Staff did not seek timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Loera met with Administrator, Noel Camatog to deliver findings on a complaint investigation conducted by the department for the allegations of, “Neglect/lack of supervision resulting in severe malnutrition, Neglect/lack of supervision resulting in unexplained pressure injuries and Staff did not seek timely medical care for resident.” Based on a review of records for both resident (listed as R1) and staff, review of police reports, hospital reports, and interviews with staff, residents and outside parties the following are our findings.

Regarding the allegation of neglect/lack of supervision resulting in severe malnutrition, R1 was seen at Marin Health Medical Center on August 11, 2024, notes described R1 to be “malnutrition – chronic”, R1 weighed 63lbs 4.4oz. On August 15, 2024 R1 weighed 54lbs and .2oz. R1 is described to have a low appetite, on a pureed diet and prescribed Ensure drinks twice a day. Facility staff indicated R1s never lost more than 3lbs in a month.

continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 2
Control Number 21-AS-20240816144447
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: CICADA-MILL VALLEY
FACILITY NUMBER: 216801993
VISIT DATE: 03/20/2025
NARRATIVE
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A record of R1s weight between July 2023 and July 2024 shows R1s weight gradually fluctuates throughout the year. R1 saw their physician regularly, there was no documented concern of malnourishment. Marin County Sheriff report determined facility staff did not willfully cause R1 to be endangered. The allegation of neglect/lack of supervision resulting in severe malnutrition is UNSUBSTANTIATED.

Regarding the allegation of neglect/lack of supervision resulting in unexplained pressure injuries, facility staff observed R1 to have a pressure wound on July 23, 2024, R1s physician was notified and an appointment was made for August 2, 2024. On August 2, 2024, R1 was diagnosed with two staged two pressure injury on their coccyx and a stage one pressure injury on their elbow. Between July 23rd and August 2nd staff were applying medical honey to R1s pressure injuries. A review of resident notes did not indicate the pressure injuries worsened during this time. Facility staff interviewed indicated R1 was not bedbound, was able to transfer and ambulate. R1 would frequently come out into the living room. When R1 eventually required a wheelchair, R1 would transfer from the wheelchair to the couch or chair. Facility notes indicate R1 was to be repositioned regularly, facility staff interviewed stated they do not keep a log or repositioning schedule. The allegation of neglect/lack of supervision resulting in unexplained pressure injures is UNSUBSTANTIATED.

Regarding the allegation of staff did not seek timely medical care, facility staff interviewed indicated that R1 had a decreased appetite but never stopped eating. R1s 2024/2025 Individual Service Plan indicates “R1 historically has fragile health…” During the August 2, 2024 visit with R1s physician, R1s physician ordered a wound care consult and cushion for seated support. On August 11, 2024 R1s health declined further and facility staff transported R1 to the ER. R1 was admitted to a local hospital. The Department attempted to interview R1s physicians, to date neither of the physicians have responded. The allegation of staff failed to seek timely medical care is UNSUBSTANTIATED.

Findings of UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2