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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 11:27:48 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
09/17/2024 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20240917163715
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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Personal Rights
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 personal rights due to staff (S1) hit client (C1) in the chest. Based on interviews that were conducted throughout the investigation, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. In addition, LPA reviewed resident records and conducted additional interviews which also could not corroborate the allegation.

It is also alleged personal rights due to S1 using derogatory language in the presence of clients C1 and C2 in S1’s native language. Interviews were conducted and based upon those statements, the following determinations have been made: Staff state that they have witnessed or heard of S1 speaking in the presence of clients in a negative manner in a language other than English. (Report continued on LIC9099-C)
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 3
Control Number 21-AS-20240917163715
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: 12/12/2024
NARRATIVE
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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.

*****REPORT AMENDED*****

The LIC9099 is being amended as civil penalties are not due.

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

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240917163715
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
80072(a)(2)
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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. This requirement was not met as evidence by:
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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, 12/13/2024. Adminsitrator to confirm training will be completed by 12/27/24.
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Based on interviews Administrator did not ensure dignity and respect in personal relationships between staff/clients. 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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3