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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:36:56 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
06/14/2022 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220614121820
FACILITY NAME:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR:LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY:5CENSUS: 5DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Leonjae Sillas Williams - staffTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Resident eloped from facility.

Facility does not have adequate staff to meet clients’ needs.

INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Leonjae Sillas Williams - staff.

On June 6, 2022, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with facility staff, interviews with staff and administrator Sherri Lott on 6/16/2022 and 6/22/2022, and documentation review including 911 records & report, Department learned that client C1’s eloped on 6/6/2022 & 6/13/2022. However, on 6/13/2022 C1 eloped twice. All the elopements occurred between 3:20 AM and 4:42 AM.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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 5
Control Number 21-AS-20220614121820
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: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 08/04/2022
NARRATIVE
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Physician’s Report (LIC 602) for client C1 dated 12/27/2021 states that client is “not able to leave facility unassisted” and ISP dated 8/1/2021 states “increase of insomnia with elopement behavior during the night”. Administrator and staff stated that there are 2 staff scheduled to work overnight (NOC shift) and on 6/6 and 6/13/2022 there were only 1 staff working at the facility. Due to facility not having the appropriated staffing during NOC shift, client C1 eloped both days and facility contacted 911 due to not having staff available to supervise client. (see copy of docs on file, confidential name list, LIC 9099-D)
Based on documentation review and interviews for the case of client C1, Department is able to prove that C1 eloped on 6/6/2022 and 6/13/2022 and facility failed to supervise client C1 due to not having adequate staff to meet C1’s needs.

According with complaint allegations “Resident eloped from facility.”; “Facility does not have adequate staff to meet clients’ needs.” 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.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220614121820
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: WALDO HOUSE
FACILITY NUMBER: 216803577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
80078(a)
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80078(a)Responsibility for Providing Care and Supervision: This requirement isn't met as evidenced by: Based on interviews, incidents&police reports facility didn't comply w/this section for 1of1 client which
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Facility agrees to submit to CCLD facility elopement plan and a statement of how they will ensure that facility has enough staff to comply with elopement plan in addition to self certification that
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which poses an immediate Health,Safety risk to clients in care.Client C1 eloped on 6/6 & 6/13/22 twice. Physician'sreport states that client is “not able to leave facility unassisted” and ISP dated 8/1/2021 states “increase of insomnia with elopement behavior during the night”.(see copies)
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clients will be supervised & kept safe by POC date of 08/05/2022.
Type A
08/05/2022
Section Cited
CCR
80065(a)
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80065(a)Personnel Requirements. This requirement is not met as evidenced by: Based on interviews and documentation received facility didn't comply on necessary staff numbers to meet needs of clients
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Facility agrees to have sufficient staff to supervise clients in care at all times. Facility to submit CCLD a plan on how to ensure that facility will have enough staff at all shifts and that clients will have their needs
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in 5 outof 5 clients which poses an immediate health, safety, personal rights risk to clients in care.Staff stated that 2 staff are scheduled to work overnight 6/6 & 6/13/2022 only 1 staff worked. Due to facility not having the appropriated staffing during NOC shift, client C1 eloped due to not having staff available to supervise client.
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me by POC due date of 08/05/2022.
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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
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