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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 12/26/2023
Date Signed: 12/26/2023 02:49:37 PM

Unsubstantiated


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
12/21/2023 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20231221135708
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: DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ezra McKinley-DSPTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility does not have an adequate supply of food
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 12:00pm on 12/26/23, and met with Ezra McKinley DSP. The LPA observed another DSP/Jerimiah on shift, and also an interpreter on-site for one of the clients in care. Administrator Sheri Lott contacted the facility stating they were on the way to meet with the LPA.

The LPA toured the facility with DSP Ezra; LPA observed a sufficienst supply of food during the inspection. LPA observed a kitchen refrigerator/freezer, downstairs there were two additional refrigerators, and a chest freezer. The LPA observed fruit, vegetables, frozen meat, frozen food items, canned goods, and other miscellaneous food item stored.


Continued on LIC9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
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 3
Control Number 21-AS-20231221135708
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: 12/26/2023
NARRATIVE
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There is differing information observed during the inspection, from what was reported to the Department. It is not known if before the inspection food was insufficient from LPA's observations of today, 12/26/23. There was no information obtained and/or observed to support a violation had occurred.

Based on LPAs observations, record reviews, and information gathered during interviews with staff, and other related parties, there is insufficient information to prove or disprove the allegation of "Facility does not have an adequate supply of food" therefore this allegation is unsubstantiated.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged abuse occurred.

No citations issued. Exit interview was conducted with Administrator Sheri Lott.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3