216804130-2-6-2024-21-AS-BMOS-D2DQNM-20240212111921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804130
Report Date: 02/06/2024
Date Signed: 02/06/2024 09:11:54 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
10/09/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231009125657

FACILITY NAME:	AVERY LANE		FACILITY NUMBER:	216804130
ADMINISTRATOR:	HILDEBRAND, CAMILLE		FACILITY TYPE:	772
ADDRESS:	200 ATHERTON AVE		TELEPHONE:	(415) 686-6127
CITY:	NOVATO	STATE: CA	ZIP CODE:	94945
CAPACITY:	6	CENSUS: 6	DATE:	02/06/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Anna-Lena Karlsson, Program Director		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff mishandled the clients medications while in care
Staff did not keep the facility free from rodents
Staff did not provide therapeutic services to the clients
Staff interfered with a client's telephone calls
Staff did not safeguard a client's confidential information
Staff harassed a client while in care
Staff do not have planned activities for the clients

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegations and met with Program Director Anna-Lena Karlsson.

During complaint investigation LPA conducted interviews with 2 staff and 5 residents, made observations at facility on 10/10/2023, 10/17/2023 & 10/26/2023 and reviewed records.

Staff mishandled the clients medications while in care- Complainant alleges client (C6) medications were mishandled on multiple occasions due to negligence of onsite staff. LPA obtained medication records for C6 which did not indicate facility staff are mishandling C6 medications. C6 refused medications on multiple occasion which were documented by the facility on medication records obtained. LPA conducted a case management on 10/17/2023 and cited facility for a medication error which did not involve C6. Additional clients medications were reviewed and LPA did not identify staff are mishandling medications.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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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Control Number 21-AS-20231009125657

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: 02/06/2024

NARRATIVE

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Although the allegation Staff mishandled the clients’ medications while in care 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.
Staff did not keep the facility free from rodents – Complainant alleges facility had a rodent problem. Facilty location is in the countryside and on 10/10/2023 during 10-day inspection LPA did not observe any indication of rodents. LPA did observe clean kitchen and pantry. LPA’s interview with Program Director Anna- Lena Karlsson revealed the facility had not been occupied for months prior to opening. The facility was licensed on August 21, 2023, shortly after rodent droppings were observed. A pest control company was contacted and treatment plan to resolve rodents began. LPA obtained documentation to confirm. The facility has not had a problem since. Documents obtained show initial pest control service, occurring on September 18, 2023 and follow up appointment on October 4, 2023. Traps set around exterior of building and in basement. There are two more follow up appointments for pest control company. LPA’s interview with staff and clients, indicate although there had been a rodent issue when the facility first opened, facility took action in a reasonable amount of time and there have not been any signs of rodents in the facility since. Therefore, the allegation is Unsubstantiated.
Staff did not provide therapeutic services to the clients – Complainant alleges facility advertised “family” and “equine therapy” that was not provided. LPA conducted interviews with staff and clients that revealed although for the first couple of weeks the facility was opened it did not have equine therapy, this was implemented within the first month. The facility did have other forms of therapeutic services; education groups with life skills 2 times per week and 3 individual case managements per week, as well as group nature hikes. LPA obtained daily structured schedule which identifies 7 days and week from 7:30am to 10:30pm. Equine therapy is offered of site for clients and family therapy is offered weekly. Although the allegation staff did not provide therapeutic services to the clients 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
Staff interfered with a client's telephone calls – Complainant alleges that clients phone conversation are interrupted. Based on LPAs interview with complainant it was revealed that a phone conversation was happening, and a staff walked into the room and requested client terminate the phone call. LPA reviewed records which indicate set times for clients to make phone calls on facility phone and clients may access personal cell phones during case management times.
Continue on LIC9099C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20231009125657

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: 02/06/2024

NARRATIVE

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Based on the investigation it was revealed staff are not interfering with phone calls but attempting to ensure clients are following house rules. Interview with client confirmed that clients may use the phone during other times if there is a just reason. LPA obtained C6 admission agreement which identifies house rules. 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.
Staff did not safeguard a client's confidential information- Complainant alleges facility gave out clients confidential medical information to another client. On 10/23/2023 LPA contacted complainant regarding allegation for additional information and was informed that they were provided clients information and could give LPA a copy for proof. LPA followed up via email on 10/24/2023 requesting the document mentioned during pre-investigation contact. LPA did not receive a response or additional information to support staff are not safeguarding client’s confidential information. LPA conducted an interview with Program Director that informed they keep all clients information safeguarded on the computer that require password and computers are located in locked room. 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.

Staff harassed a client while in care – Complaint alleges that facility staff berated client for allegedly filing a complaint. Per complaint allegation, staff listened in on a phone call, referenced the phone log and harassed client in an effort to find out what was allegedly filed. Client interview clarified that staff did not retaliate but made client uncomfortable. Staff denied allegation stating that they had not asked any clients about any alleged complaints.” 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.
Staff do not have planned activities for the clients – Complainant alleges facility does not provide planned activities. LPA obtained schedule of facility for week of 9/22/2023. Schedule indicates planned activities from 8:30 am until 8:30 pm, including; yoga, cooking with a chef, individual & group therapy, movie nights and nature outings to name a few. Interviews with 4 clients revealed they go to the beach and enjoy the music, games, arts & crafts the facility provides. LPA observed activities while present at the facility on 10/10/2023, 10/17/2023 & 10/26/2023 Although the allegation Staff do not have planned activities for the clients 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: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC9099 (FAS) - (06/04)

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