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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803711
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:35:46 PM

Unsubstantiated


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
09/09/2024 and conducted by Evaluator Anthony Loera
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240909104821
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:
11/18/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Administrator, Willie HoganTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not prevent resident from self harming.
Staff are falsifying incident reports.
Staff are not administering medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Loera and Licensing Program Manager (LPM) Mota arrived unannounced and met with adminstrator to complete the complaint investigation and deliver findings. During the course of this investigation, records were reviewed, observations made, and interviews conducted.

It is alleged that on 9/2/2024, Client (C1) was in crisis and staff immediately called police rather than attempt to redirect C1 prior to calling 911. Through record review and interviews, it was learned that C1 had been playing on their phone when for unknown reasons, threw the phone, jumped on the back of a couch and began screaming and banging their head on the wall. Staff (S1, S2, S3) attempted to redirect C1 for approximately 10 minutes without success.

continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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-20240909104821
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: 11/18/2024
NARRATIVE
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Due to C1 possibly injuring themselves by banging their head on the wall, 911 was called and police arrived. A review of police records for this date indicate that staff were not responding to the police dispatcher and that dispatch could hear a female screaming.

It is alleged staff are not administering medications as prescribed. LPA and LPM reviewed C1’s Medication Administration Record (MAR) and found that C1 was administered medication as prescribed and not over-medicated as alleged. In addition, staff interviews did not reveal that staff were purposely over-medicating C1.

It is alleged that staff are falsifying incident reports. LPA and LPM reviewed records and conducted interviews. Records do not show that there is any documentation that C1 performed SIB more than what had occurred or showing any dates with SIB of 20. Staff that were interviewed did not state that they had knowledge of documents being falsified or being told if C1 hits themselves one time and staff can not stop them, to document it as 20 times. Record review and staff interviews revealed that on 7/22/2024, C1 did kick Client (C2) on the right leg

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2