216803711-1-23-2025-21-AS-KMOA-DDEUV4-20250130145430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803711
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:14:38 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
11/22/2024 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20241122110450

FACILITY NAME:	SYCAMORE HOME		FACILITY NUMBER:	216803711
ADMINISTRATOR:	HOGAN,WILLIE		FACILITY TYPE:	735
ADDRESS:	75 JUANITA COURT		TELEPHONE:	(415) 761-9790
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	4	CENSUS: 3	DATE:	01/23/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Willie Hogan, Administrator Kevin Nunez, House Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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On 01/23/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Administrator, Willie Hogan. During the course of the investigation, LPA reviewed records, conducted interviews with staff and outside parties, and made observations.

Compliant alleges, Personal Rights. Report was received 11/22/2024, alleged staff did not try to stop client from self-harm as client broke responsible party’s rear-view mirror then went on the floor and started banging their head and hands while screaming.

Based upon department interviews with staff, information provided was contradicting with a lack of corroborating evidence to support the allegation. According to Client 1’s (C1) individualized behavioral support plan (dated 10/11/2024) when in the front yard, the level of supervision required for staff is “within arm’s reach: staff is within arm’s reach of a client at all times specified. That is, if staff were to extend their arms, they would be close enough to touch the client’s shoulder.”

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20241122110450

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: 01/23/2025

NARRATIVE

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According to Client 1’s (C1) individualized behavioral support plan (dated 10/11/2024) when in the front yard, the level of supervision required for staff is “within arm’s reach: staff is within arm’s reach of a client at all times specified. That is, if staff were to extend their arms, they would be close enough to touch the client’s shoulder.” In Client 1’s (C1) Behavior Support Plan under target behavior #4, Agitation is defined as “any instance of crying, screaming, whining.” When C1 is agitated, the behavioral support plan refers to see strategies outlined under “aggression”. The proactive strategies for “aggression” are to follow supervision guidelines which states “in general, staff should be within arm’s length at all times.” Based on interviews and reviewed records staff were within arm’s reach to C1 as staff were able to put their hands under their head to prevent injury. In C1s individualized behavioral support plan (dated 10/11/2024), it states C1 is afraid of dogs. During the incident, C1’s responsible party had dogs with them. It is unknown if this agitated C1 more during the incident.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC9099 (FAS) - (06/04)

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