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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804130
Report Date: 10/26/2023
Date Signed: 10/26/2023 02:22:58 PM

Substantiated


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
09/22/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230922132443
FACILITY NAME:AVERY LANEFACILITY NUMBER:
216804130
ADMINISTRATOR:HILDEBRAND, CAMILLEFACILITY TYPE:
772
ADDRESS:200 ATHERTON AVETELEPHONE:
(415) 686-6127
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:6CENSUS: 3DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Program Director Anna-Lena KarlssonTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff prevent clients from having visitors
INVESTIGATION FINDINGS:
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Licensing program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegation and was welcomed by Clinical Director Steph Rothman who contacted Program Director Anna-Lena Karlsson and arrived shortly after.

Staff prevent clients from having visitors – Complainant alleges facility is not allowing clients to have visitors. The department conducted unannounced visits at the facility on 9/20/2023, 10/10/2023, & 10/17/2023, during visits LPA interviewed 5 clients that stated, when the facility first opened at the end of August 2023 visits were not allowed. On 10/17/2023 LPA’s interview with Program Director Anna-Lena Karlsson acknowledged the facility opened on 8/21/2023 with the first clients. Program Director further informed at licensure; the facility was not allowing visitors. Director stated this was due to safety concerns for the population being served as well as COVID protocols.

Continue on LIC9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 3
Control Number 21-AS-20230922132443
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: AVERY LANE
FACILITY NUMBER: 216804130
VISIT DATE: 10/26/2023
NARRATIVE
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After discussions with clients and research of personal rights, facility changed their policy and started visits on weekends, beginning 9/24/2023. Investigation revealed the allegation of staff prevent clients from having visitors is Substantiated.

Based on LPA’s observations, records reviewed, and interviews with clients and staff, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230922132443
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: AVERY LANE
FACILITY NUMBER: 216804130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
81072(a)(14)
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(a) Each client shall have personal rights which include, but are not limited to, the following: (14)To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This requirement is not met as evidenced by:
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Facility began visiting on 9/24/2023 and has updated visit schedule as of 10/26/2023 to allowing visits Saturdays & Sundays 1PM to 4PM. Deficiency cleared at time of visit.
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Based on interviews, record review the licensee did not comply with the section cited above, and allowing visitors, which poses a possible risk to the health, safety or personal rights risk to persons in care.
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Deficiency cleared at time of visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3