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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803917
Report Date: 10/09/2025
Date Signed: 10/09/2025 02:46:30 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
09/30/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20250930155031
FACILITY NAME:SHALAMO HOMEFACILITY NUMBER:
216803917
ADMINISTRATOR:GONGORA,JASMINFACILITY TYPE:
737
ADDRESS:200 DARYL AVENUETELEPHONE:
(415) 493-6622
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 4DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator Jasmin GongoraTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee allows untrained staff to dispense medications to clients in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 2:05 PM Licensing Program Analyst (LPA) Star Stevenson arrived to deliver findings related to a compliant of, "Licensee allows untrained staff to dispense medications to clients in care".
LPA conducted interviews and document review. LPA obtained evidence of both S1 and S2 having received their required 32 hours of on-the-job training within their first 40 hours of work, including "1 hour of Assisting with Medications" training.
In addition, interviews with Administrator and Lead Caregiver (S3), as well as, Complianant (C1) indicate Shalamo Home always has a lead caregiver, and four (4) caregivers on staff at all times. California Code of Regulations -CCR 89965(d) indicates, "Direct Care staff who have not completed the on-site training as required by CCR, Title 17,Section 59063 shall be under the direct supervision and observation of a fully trained care Lead Staff person while caring for clients, and shall not be permitted to be alone with clients"

Because the training is documented and because a lead staff are always present, the complaint is Unsubstantiated. A finding of unsubstantiated means although the alligation may have happned or is vaild, there is not a preponderance of evidence to prove the alleged violation did occur.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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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