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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:07:46 AM

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
12/14/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20221214133305
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:
12/16/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Staff, Robinson BermudezTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff not providing adequate supervision to resident(s) in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Complaint Investigation regarding the above allegation and met with Staff, Robinson Bermudez. LPA spoke with Administrator, Sheri Lott who gave permission for staff to sign report.

Staff not providing adequate supervision to resident(s) in care - LPA has reviewed reports from the facility of client, C1 eloping facility twice within the last weeks. Both times staff were unable to maintain line of sight supervision and C1 was returned to the facility by the police. Per discussion with Administrator, there is a meeting planned today to discuss the increased elopement behavior and how staff will ensure client safety.

Civil Penalties are being assessed in the amount of $250 due to a repeat citation issued for the same subsection in less than 12 months.

Deficiencies 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 3
Control Number 21-AS-20221214133305
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: WALDO HOUSE
FACILITY NUMBER: 216803577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on record review and interview, client C1 eloped facility twice within the last week and staff was unable to maintian supervision. C1 was returned to the facility
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Per Administrator a meeting is planned for today to determine next steps to ensure the safety of C1. Administrator will submit that plan to LPA by POC due date, 12/17/2022.
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by the police. This poses an immediate Health and Safety risk to clients in care.

Civil Penalties are being assessed in the amount of $250 due to a repeat citation issued for the same subsection in less than 12 months.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3