216803577-9-23-2025-21-AS-BMOS-DLYNGH-20250929102709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 09/23/2025
Date Signed: 09/23/2025 09:35:21 AM

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
06/02/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250602155927

FACILITY NAME:	WALDO HOUSE		FACILITY NUMBER:	216803577
ADMINISTRATOR:	LOTT, SHERI		FACILITY TYPE:	735
ADDRESS:	55 WALDO COURT		TELEPHONE:	(415) 271-3304
CITY:	SAUSALITO	STATE: CA	ZIP CODE:	94965
CAPACITY:	5	CENSUS: 5	DATE:	09/23/2025
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Tanya Barreto, House Manager		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff caused injury to client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegation listed above. LPA was greeted by House Manager Tanya Barreto. LPA contacted Administrator who authorized House Manager to sign for today's visit. During today's visit, there was 3 staff and 4 clients, 1 client is still in the hospital.

During investigation LPA made observations, reviewed documents and conducted interviews.

Staff caused injury to client in care- Reporting party informed there was an incident report submitted for client (C1) of an injury that occurred on 11/14/2024 and has since been reported that said injury was allegedly caused by a staff member. 11/14/2024 CCL received the self-reported incident informing of C1’s self-inflicted injury due to behaviors. Investigation revealed staff (S5) indicated at approximately (11:20 pm) 45 minutes before end of shift, while alone at facility with 4 clients (see CM regarding citation for lack of supervision), S5 informed C1 had behaviors resulting in injury, S5 attempted to redirect and calm C1 down.
Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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-20250602155927

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: 09/23/2025

NARRATIVE

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Continued from LIC9099

S5 attempted to contact C1’s conservator and was not successful and management was not contacted at time of incident. S5 and S2 at shift change had communication of S1’s active behaviors per S5. When S5 returned approximately an hour later C1 was in ambulance with head wrapped in bandages. Interview with S2 revealed the start of shift found a lot of blood on the floors and found C1 was bleeding from a cut on their head and was walking around the house. S2 called the supervisor right away, called 911 and administered first Aid to C1. Administrator interview indicated S5 refused to come into the office and discuss what happened and was terminated. Interview with S5 contradicted Administrator indicating they tried to discuss situation with Management following day but was informed they were not allowed on the property until the investigation was complete and did not discuss the situation with S5 further. Based on client record review has a history of self injury behavior. Based on interview 9/15/2025 and final report obtained from Law enforcement indicated their investigation revealed no evidence of alleged abuse. Declaration was obtained by C2 indicates did not see anything of this incident. LPA conducted and attempted to conduct additional interviews with staff and clients which did not reveal information that staff caused injury to client in care. Therefore, the allegation is Unsubstantiated.

A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC9099 (FAS) - (06/04)

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