<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 01/02/2024
Date Signed: 01/02/2024 04:30:20 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
12/28/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231228120454
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: 4DATE:
01/02/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paula Sifflet-Regional ManagerTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility illegally evicted a resident in care.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 11:00am on 1/2/24 and met with Paula Sifflet, Regional Manager (RM). The LPA observed two staff on duty with the clients in care, DSPs Ezra and Jereimiah. DSP Jeremiah directed the LPA down the stairs to the facility office, where RM Paula was working, located on the ground level.

LPA obtained copies of client care plans, behavior intervention plans, medication orders, medication logs. LPA reviewed medication log binder of medications prescribed, including all PRNs.The LPA toured the facility with RM Paula. The LPA reviewed client files, facility records, interviewed staff, and other related parties, the investigation revealed that the facility had reassessed the client and made the decision to not have the client returned return to the facility. The client had received an eviction notice approximately a year ago, but had not been moved out by responsible partie(s).

Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
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 6
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
12/28/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231228120454

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: 4DATE:
01/02/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paula Sifflet-Regional ManagerTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent a resident from ingesting foreign objects.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 11:00am on 1/2/24 and met with Paula Siffet, Regional Manager (RM). The LPA observed two staff on duty with the clients in care, DSPs Ezra and Jereimiah. DSP Jeremiah directed the LPA down the stairs to the facility office, where RM Paula was working, located on the ground level.

LPA obtained copies of client care plans, behavior intervention plans, medication orders, medication logs. LPA reviewed medication log binder of medications prescribed, including all PRNs.The LPA toured the facility with RM Paula. The LPA reviewed client files, facility records, interviewed staff, and other related parties, the investigation revealed that the client (C1) is to be in line of sight of staff supervison. The facility is not funded for one on one care for C1 but, the facility does use a staff on duty to provide closer supervision to C1 due to the clients behaviors. RM stated they use one of the staff on shift to be with C1 and monitor them closely, providing more supervison for C1.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20231228120454
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: 01/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews with staff revealed, staff try to ensure the client does not do anything, like awol, hit any other client, swallowing items and/or ingesting foreign objects, but the client did this recently without staff's knowledge. The client told staff that they swallowed some foreign objects. The Administrator, Sherri Lott, took the client to the emergency department; The client was admitted into the hospital for medical care needed on 12/26/23.

Per review of facility records, interviews with staff, and other parties, the staff didn't prevent the client from swallowing foreign objects, a nail, batteries, and a tack/pushpin; Staff that are said to be providing line of sight, close supervision, were not aware that the client had swallowed these items. There were four other clients in the home with C1 at the time of this incident. C1 told the Administrator of swallowing objects, this is when the client was assessed by staff, and then taken for a professional medical assessment at the Emergency Department.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of staff did not prevent a resident from ingesting foreign objects, has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, 80078 (a) Responsibility for Providing Care and Supervision, The licensee shall provide care and supervision as necessary to meet the client's needs-see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Exit interview conducted with RM Paula Sifflet.
Appeal Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20231228120454
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: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 (a) Responsibility for Providing Care and Supervision, The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: LPA's review of records, interviews with staff, and other parties, Facility staff were not aware that the client
1
2
3
4
5
6
7
Licensee/Administrator to ensure that facility is meeting the needs of clients in care at all times, Ensure sufficient staffing to meet all clients needs, including all behaviors. Submit plan of future compliance with this regulation requirement. POC due by 1/3/24.
8
9
10
11
12
13
14
had swallowed a nail, batteries, and a tack/pushpin. The client C1 is provided close supervision by staff on duty per interview with staff/RM. C1 told the Admnistrator they swallowed objects, and Administrator took the client to the Emergency department. This is a risk to the health & safety of the client/clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20231228120454
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: 01/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The client went into the hospital from the facility/ Waldo House on 12/26/23; The facility refused to accept the client (C1) back into care. Per interviews the client was reassessed by facility staff to not be appropriate for the facility and the facility not able to meet C1's needs at this time.

Per review of facility records, interviews with staff, and other parties, the staff didn't prevent the client from swallowing foreign objects, a nail, batteries, and a tack/pushpin; Staff that are said to be providing line of sight, close supervision, were not aware that the client had swallowed these items. There were four other clients in the home with C1 at the time of this incident. C1 told the Administrator of swallowing objects, this is when the client was assessed by staff, and then taken for a professional medical assessment at the Emergency Department. Since this incident, the facility refused C1 to be discharged back to the facility.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of facility illegally evicted a resident in care., has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today,80068.5 (a)(b) Eviction Procedures - Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons: The licensee shall obtain prior written approval from the Department to evict the client upon three (3) days written notice to quit and upon a finding of good cause. -see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Exit interview conducted with RM Paula Sifflet.
Appeal Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20231228120454
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: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
80068.5(a)(b)
1
2
3
4
5
6
7
(a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons: A three day's written notice with Licensing Department approval only. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to ensure all clients are provided 30 day written notice as reqiuired, ensuring that until client is moved out the facility continues to provide all care and supervision to the client. Please submit plan of future compliance with this regulation. POC due 1/12/24
8
9
10
11
12
13
14
Per LPA's record reviews, and interviews with staff ^& other parties, the facility refused to have the client C1 come back to the facility when discharged. Facility staff reassessed the client and state they can't meet the clients needs. This is a risk to resident's personal rights.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6