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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803917
Report Date: 10/23/2024
Date Signed: 10/23/2024 10:51:42 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
07/16/2024 and conducted by Evaluator Kimberley Mota
COMPLAINT CONTROL NUMBER: 21-AS-20240716113901
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:
10/23/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Kasandra Renteria, Leader BTTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Staff are not adequately supervising resident(s) in care.
Staff are not ensuring that resident's needs are being met.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Mota arrived unannounced for the purpose of delivering findings on this complaint. Administrator was available via phone. In addition, staff Kasandra Reneria was given approval to sign the report.
This investigation has included statements from staff and witnesses, review of documents, photographs and videos from various vantage points throughout the neighborhood. The following determinations are made: A client (C1) has left facility on more than one occasion and exhibited inappropriate behaviors in the neighborhood; The behaviors have included damaging property, trespassing, yelling and screaming, throwing items at neighbors and indecent exposure; Per C1's Behavior Plan, C1 is supervised by a 2 to 1 ratio (meaning 2 staff are present with C1 at all times) and the facility is adequately staffed; Staff have been present when C1 has left the facility and have used approved techniques to redirect and restrain C1 when necessary; C1's behaviors which are unlawful have been brought to the attention of law enforcement and such behaviors remain within the jurisdiction of police agencies. Although the allegations may be true, based on statements and reviewed documents, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the complaint is UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: Kimberley Mota
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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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