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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803917
Report Date: 11/20/2023
Date Signed: 11/20/2023 09:49:20 AM

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
10/05/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231005150844
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: 1DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Lakien Zamarron (staff)TIME COMPLETED:
10:03 AM
ALLEGATION(S):
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-Personal Rights.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with staff Lakien Zamarron.

There is an allegation regarding Personal Rights. Per Reporting Party, staff members (names unknown) have been smoking in the no smoking zone area, staff member observed was smoking in an open field behind the facility one time around 7pm and they left a large amount of cigarette butts on the ground, there are concerns about the cigarettes igniting a fire. Based on records review, there is no use of oxygen on the premises. Based on written statements obtained from the Administrator and staff (S1), revealed that the incident reported by the reporting party did occur. Per S1’s written statement: “they were told not to smoke on the trail next to the facility, then S1 picked up cigarette butts and haven’t smoked over there since requested”. Administrator has confirmed that the incident happened during S1’s break. However, S1 was taking their break and they as employer can only encourage all staff not to smoke closer to the home.
Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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-20231005150844
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: 11/20/2023
NARRATIVE
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Continued from LIC9099...

Although incidents about smoking occurred, there is no supporting information that personal rights of clients in care were violated. During confidential interviews conducted with staff, it was confirmed that the facility has a non-smoking sign located through the home and they do understand the harm that smoke represents a hazard to the safety of clients in care as well as the home. A finding that the complaint personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2