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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 06/17/2025
Date Signed: 06/17/2025 03:07:10 PM

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
03/17/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250317144851
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:
06/17/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lead Staff, Tanya BarretoTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff speaks inappropriately to resident
INVESTIGATION FINDINGS:
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On 06/17/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Lead Staff, Tanya Barreto. During the investigation, LPA reviewed records, conducted interviews, and made observations.

Complaint alleges, Staff handled resident in a rough manner and staff speaks inappropriately to resident.

Based on LPAs observations, record reviews, and interviews of 4 of 5 staff and outside parties, the following determination have been made. Facility documentation was provided to LPA on 03/24/2025 showing staff (S1) was suspended due to speaking inappropriately to Client (C1), stating they would have to cancel C1s meeting with their mom as C1 was not following directions. Additional documentation received revealed C1 was seen by a physician to address back pain on 03/14/2025 after being "yanked" by S1. Therefore, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, is being cited on the attached LIC9099D. Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20250317144851
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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidence by:
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Facility to ensure the protection of personal rights for all clients. Lead staff agrees to conduct Personal Rights training per Regulation 80072 for all staff. Proof of scheduled training to be submitted to CCL by POC due date, 06/18/2025. Lead staff to confirm training will be completed by 07/01/25.
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Based on interviews and documentation review, facility did not ensure dignity and respect to C1 as staff spoke inappropriately and handled C1 in a rough manner. This is an immediate health and safety risk to client in care.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
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