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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803711
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:38:14 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
05/14/2024 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20240514220121
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR:MARTIN, GAMALIEL DAN G.FACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:4CENSUS: DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff physically abused a client while in care resulting in injury
Staff did not properly report an incident involving a client
INVESTIGATION FINDINGS:
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi and Licensing Program Analyst Anthony Lorea met with Licensees Marisol Hogan and Ian Mauricio to deliver findings regarding the above mentioned allegations.

The Department conducted a complaint investigation into; “staff physically abused a client while in care resulting in injury”. The complaint alleges that clients have been physically abused by staff resulting in injury. Based on the Department’s investigation which included multiple interviews, review of physical and electronic documents, and review of photos and video, the preponderance of evidence has been met. Ten staff were interviewed and six of those staff reported observation of clients being abused and or/restrained. One staff has been arrested and received an immediate exclusion from the Department.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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-20240514220121
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: SYCAMORE HOME
FACILITY NUMBER: 216803711
VISIT DATE: 09/06/2024
NARRATIVE
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Continued from LIC9099

Complaint alleges that “staff did not properly report an incident involving a client". Based on review of records and interviews, Administrator and staff who witnessed abuse or received information regarding allegations of abuse did not properly report incidents via an SOC341 Report of Suspected Dependent Adult/Elder Abuse per mandatory reporting requirements and/or a Special Incident Report (SIR) to the Department alerting of alleged abuse.

Civil penalties are under review per Section 15610.63 of the Welfare and Institutions Code.
A non-compliance conference is scheduled.

Based on information received during the complaint investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240514220121
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: SYCAMORE HOME
FACILITY NUMBER: 216803711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2024
Section Cited
CCR
80072(a)(3)
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80072(a)(3) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse
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Licensee agrees to have a training scheduled by COB on September 10th with an outside vendor and training will be completed for all staff on all shifts by September 30th.
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or other actions of a punitive nature ...Requirement isn't met as evidence by: Based on interviews, review of photos and videos & review of documents, Licensee didn't ensure regulation was met by client being physically abused by staff. This is an immediate risk to clients in care.
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Type A
09/10/2024
Section Cited
CCR
80061(b)(1)(E)
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80061(b)(1)(E) Reporting Requirements (b) Upon the occurrence... a report shall be made to the licensing agency within the agency's next working day during its normal business hours.In addition, a written report containing the information specified in (2) below shall be submitted to the Licensing
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Licensee agrees that all staff on all shifts will be retrained on reporting requirements including Mandated Reporter requirements and how to report on an SOC341 Report of Suspected Dependent Adult/Elder Abuse.
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to the licensing agency within 7 days following occurrence event..Any unusual incident which threatens the physical or emotional health or safety of a client. Requirement isn't met as evidence by: Based on interviews, Licensee didn't ensure abuse was reported timely.
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The training will be scheduled by COB on September 10th with an outside vendor and training will be completed for all staff on all shifts by September 30th.
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: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/14/2024 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20240514220121

FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR:MARTIN, GAMALIEL DAN G.FACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:4CENSUS: DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for a client
INVESTIGATION FINDINGS:
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi and Licensing Program Analyst Anthony Lorea met with Licensees Marisol Hogan and Ian Mauricio to deliver findings regarding the above mentioned allegation.

Staff did not seek timely medical attention for a client – Complaint alleges that the client was observed with a black eye in February 2024. When staff was questioned, they explained that the client hurt themselves and was assessed by staff for a concussion. Client was not taken to the ER. It could not be confirmed that client’s injury warranted an emergency room visit.

A finding that the complaint allegation Staff did not seek timely medical attention for a client unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5