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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803711
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:26:22 AM

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
12/02/2024 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20241202150508
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:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Willie Hogan, AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not follow client’s feeding plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Loera 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.

Complaint alleges staff did not follow client’s feeding plan due to staff (S1) giving client (C1) a fig bar without making it puree. Interviews were conducted and based upon those statements, the following determinations have been made: Staff stated they witnessed S1 giving C1 a fig bar without making it puree.

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: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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-20241202150508
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
80076(a)(6)(A)
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80076 (a) In facilities providing meals to clients, the following shall apply: (6) Modified diets prescribed by a client's physician as a medical necessity shall be provided. (A) The licensee shall obtain and follow instructions from the physician or dietitian on the preparation of the modified diet.
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Administrator agrees to conduct food services training per Regulation 80076 for all staff. Proof of training to be submitted to CCL by POC due date, 12/13/2024. Adminsitrator to confirm training will be completed by 12/27/24.
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This requirement was not met as evidenced by: Based on interviews, Staff witnessed S1 giving non puree food to C1. This is an immediate health and safety 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2