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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803917
Report Date: 07/08/2022
Date Signed: 07/08/2022 12:40:42 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
04/04/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220404104956
FACILITY NAME:SHALAMO HOMEFACILITY NUMBER:
216803917
ADMINISTRATOR:KIMBO, ANGELINEFACILITY TYPE:
737
ADDRESS:200 DARYL AVENUETELEPHONE:
(415) 493-6622
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 3DATE:
07/08/2022
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Licensee, Priscilla Kimbo and Administrator Angeline KimboTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to resident in care
Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis met with Licensee, Priscilla Kimbo and Administrator Angeline Kimbo to deliver findings regarding the above complaint allegations.

During investigation, CCL conducted interviews, obtained documents and reviewed video.

Staff did not provide adequate supervision to resident in care - Complaint alleges that on or around 3/23/22, a client was observed in the front yard with their pants down and there were no staff supervising the client. Complaint alleges that this has happened multiple times. LPA was provided video of an incident dated 4/28/2022 where an individual walked beyond the front fence of the facility and is visible from the street. Per interview, the client pulled their pants down but LPA was unable to confirm this from watching the video. LPA observed two individuals, assumed to be staff, within line of sight of the client for the duration of the video. Review of client’s care plan from February 2022 states that client receives one to one supervision during waking hours.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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-20220404104956
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: SHALAMO HOME
FACILITY NUMBER: 216803917
VISIT DATE: 07/08/2022
NARRATIVE
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Continued from LIC9099

Complaint further alleges that a neighbor had to walk to the front door of the facility to alert staff that a client was outside, but LPA was unable to confirm through interviews that this happened. Additional interviews described witnesses seeing clients in the front yard without staff for a minute or two while others stated they did not see clients unsupervised.

Personal Rights – Complaint alleges that staff were observed drinking alcohol prior to going into the facility. Further interview revealed that witness could not confirm that the individual was a staff member.

A finding that the complaint allegations Staff did not provide adequate supervision to client in care and Personal Rights, was UNSUBSTANTIATED meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2