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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:20:59 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:
02/03/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff, Robinson BermudezTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not communicating with authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Staff, Robinson Bermudez. Administrator, Sherri Lott was available by phone.

Staff not communicating with authorized representative – Complaint alleges that a client’s authorized representative was not notified of the client’s elopement. Per LPA review of police reports where client, C1 left the facility unassisted there were two elopement events that were not reported to CCL, the client’s Conservator, or the Regional Center. Per interview with facility Administrator, they were unaware of a client elopement on the days reported by the police.

The allegation that staff are not communicating with authorized representative is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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-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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
80061(f)
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80061 Reporting Requirement (f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any. This requirement was not met based on the following: Based on document review and interviews, the client’s authorized representative was not notified of the client’s elopement in two out of six
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Facility agrees to submit a policy outlining how they will document communication with client’s authorized representative per regulation 80061 by POC due date, 2/10/2023.
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elopement events.
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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: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2