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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803711
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:27:01 PM

Document Has Been Signed on 09/06/2024 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
216803711
ADMINISTRATOR/
DIRECTOR:		HOGAN,WILLIEFACILITY TYPE:
735
ADDRESS:75 JUANITA COURTTELEPHONE:
(415) 761-9790
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 4CENSUS: DATE:
09/06/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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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 address areas on non-compliance.

In May of 2024, the Department received a complaint alleging staff physically abused a client in care resulting in injury – Based on the complaint investigation the Department substantiated the allegation that staff physically abused a client in care and staff failed to report an incident involving a client. The staff involved was arrested. Administrator has resigned and House Manager has stepped in as Administrator.

The following areas of non-compliance were addressed during the meeting today:
- Personal Rights/Abuse violations against staff
- Reporting requirements
- Mandated Reporter training for ALL staff on ALL shifts
- Inappropriate restraints
- Administrator Qualifications and Duties

Additionally, the Department delivered complaint findings during the meeting today for complaint # 21-AS-20240514220121. And cited additional areas of observed deficiencies from the investigation during the office visit.

Facility is being put on a two-year non-compliance plan. Facility will be referred for Technical Support. Resources were provided.
Licensee was noticed of a civil penalty under review for per section 15610.63 of the Welfare and Institutions Code.
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.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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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.

Inappropriate restraints – A training will be scheduled to ALL staff on appropriate redirection techniques and de-escalation strategies. If restraints are used ALL staff must have proper training on file to engage a restraint if warranted and copies of training and certification must be on file for review at any time. 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.

- Administrator Qualifications and Duties – Licensee will ensure oversight of Administrator. Licensee will ensure new Administrator has all necessary training and that it is on file for review at any time by the Department.

Licensee has been offered Technical Support Program (TSP) resources and has accepted the additional support; RO will submit a TSP referral.

Facility has agreed to be on a Non-Compliance Plan (NCC) for a period of two (2) years effective today.

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
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Document Has Been Signed on 09/06/2024 01:27 PM - It Cannot Be Edited


Created By: Anthony Loera On 09/06/2024 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
09/10/2024
Section Cited
CCR
80064(a)(3)

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80064(a)(3) Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.
This requirement is not met as evidence by:
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Licensee agrees to submit self certificaiton that they will ensure ongoing oversight of Administrator by POC due date, 9/10/2024.
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Based on interviews, staff reported allegations of abuse to the Administrator who failed to report, as required, or address the allegations to ensure the safety of clients in care. This is an immediate risk to the health and safety of clients in care.
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Type B
09/30/2024
Section Cited
HSC1531.1(h)(2)

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H&S 1531.1(h)(2) Residential facilities with persons having developmental disabilities...(g) Facility shall develop a plan of operation approved by the State Department of Social Services that includes... (2) A description how the facility will ensure the protection of residents’ personal rights consistent with
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Licensee to update their Plan of Operation to include processes and Protocols regarding the use of manual restraints and identifying how staff will be trained for physical restraints by POC due date, 9/30/2024.
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Sections 4502, 4503, & 4504 of the Welfare & Institutions Code.Requirement not met as evidence by: Based on interviews, staff do manual restraints, however, the Program doesn't refer to the intention of restraining clients. This is a potential risk to clients 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.
SUPERVISOR'S 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


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