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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803711
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:42:59 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
09/11/2024 and conducted by Evaluator Kimberley Mota
COMPLAINT CONTROL NUMBER: 21-AS-20240911084846
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR:HOGAN,WILLIEFACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:4CENSUS: 4DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Willie Hogan, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not accord privacy to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Manager (LPM) Mota arrived unannounced and met with Willie Hogan, Administrator to complete the complaint investigation and deliver findings. During the course of this investigation, records were reviewed, observations made, and interviews conducted.

During the course of the investigation, interviews and documents reviewed revealed that a video recording of Client (C1) was obtained while C1 was in crisis while undressed in their bed. Interviews confirmed that staff were told to record visually when C1 is in crisis and performing self-injurious behavior (SIB).

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1), is being cited on the attached LIC 9099D. Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: Kimberley Mota
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 2
Control Number 21-AS-20240911084846
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: SYCAMORE HOME
FACILITY NUMBER: 216803711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
Administrator to ensure the protection of personal rights for all clients. Administrator agrees to conduct Personal Rights training per Regulation 80072 for all staff. Proof of training to be submitted to CCL by POC due date, 10/24/2024.Adminsitrator to confirm training will be completed by 10/31/24.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on interviews and video evidence Administrator did not ensure dignity and respect in personal relationships between staff/clients. Video evidence shows C1 recorded, unclothed with SIB. This is an immediate health and safety risk to 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: Carla Martinez
LICENSING EVALUATOR NAME: Kimberley Mota
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2