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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 01/02/2024
Date Signed: 01/02/2024 04:31:29 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
12/21/2023 and conducted by Evaluator Dina Alviso
PUBLIC
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: 4DATE:
01/02/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paula Sifflet-Regional ManagerTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility does not have sufficient staffing

INVESTIGATION FINDINGS:
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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 facility had a visitor to the home that helped the one staff on shift with clients in care; Interviews and information obtained revealed that the staff was to have another on shift with them but they were not at the facility when the visitor of a resident arrived to the facility to drop off a client.
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 5
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: 01/02/2024
NARRATIVE
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RM Paula stated to the LPA they were aware of a day that one of the two staff on duty had made a run to pick-up an order of pizza for the facility. RM Paula did state that this is not something the facility would be say was allowed, staff is needed on-site. An incident occurred recently, where a client (C1) swallowed batteries, a nail, and a tack/pushpin and was hospitalized due to swallowing the foreign objects. C1 is said to be on a close supervision by staff on duty, one of the two staff is assigned to follow C1 and monitor the client closely. Staff were unaware that C1 had swallowed the nail, batteries, and tack/pushpin until the client (C1) told the facility Administrator. C1 is to be in line of supervision due to client's behaviors. LPA obtained care plan and behavior intervention plan. RM Paula stated that the facility has lost four staff since October 2023, and it has been difficult to hire new staff. There were five clients in care during these two incidents that occurred, mentioned in the above write-up.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of Facility does not have sufficient staffing, has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, Personnel Requirements 80065 (a)Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such 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: 4 of 5
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
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
80065(a)
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Personnel Requirements 80065 (a)Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by: LPA review of records, interviews with staff and other parties, it was revealed
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Licensee to ensure sufficient staffing to meet the needs of all clients in care at all times. The staffing must be sufficient in numbers to meet the needs of client behaviors to ensure client needs are met. Submit plan of correction and future compliance with this regulation.
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that a staff of two on duty left the facility to pick up pizza and the staff left on-site requested assistance from a visitor to the facility who was dropping off a client; An incident of C1 swallowing batteries, a nail, and a pushpin/tack, and staff were not aware, till C1 told the Administrator. C1 is said to be line of sight supervision and closely monitored due to behaviors. This is a risk to clients personal rights and health and safety.
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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: 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: 5 of 5