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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803863
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:32:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/18/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20230918110244
FACILITY NAME:TENDER RESIDENTIAL HOMEFACILITY NUMBER:
216803863
ADMINISTRATOR:NDOMO, RODRIGUEFACILITY TYPE:
737
ADDRESS:257 BLACKSTONE DRIVETELEPHONE:
(628) 253-5468
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:3CENSUS: 3DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Rodrigue NdomoTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff providing clients with drugs and alcohol
INVESTIGATION FINDINGS:
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At approximately 12:00PM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver Complaint Findings regarding the above allegation and met with Administrator, Rodrigue Ndomo.
During the course of the Investigation, LPA Felias requested and reviewed documents, conducted interviews and made observations. There is an allegation that Staff are providing clients with drugs and alcohol. Reporting Party stated that the facility staff offers clients marijuana and wine, does not take care of clients, and that the home is dangerous.

LPA conducted interviews with staff, clients, and outside parties. 5 of 6 interviews conducted stated that drugs and alcohol have never been provided or offered to clients. Based on interviews conducted, the LPA is unable to determine if a violation of Title 22 Regulations has occurred due to conflicting information provided during interviews. Therefore, the allegation is Unsubstantiated.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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-20230918110244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863
VISIT DATE: 12/14/2023
NARRATIVE
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Continued from LIC9099

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2