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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804130
Report Date: 06/18/2024
Date Signed: 06/18/2024 10:02:07 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
05/13/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240513131231
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: 5DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jade DolciniTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
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8
9
Licensee does not ensure sufficient staff to meet resident's needs
INVESTIGATION FINDINGS:
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2
3
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5
6
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8
9
10
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12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this Complaint. During the course of this investigation, statements were taken from clients, staff and witnesses; site visits were made to the facility; as well as documents obtained and reviewed. The following determinations are made: Several staff and the Complainant have expressed concern that the Program is understaffed and that a staffing shortage could effect the ability to meet the needs of the clients in care; No incidents were identified that would indicate a lack of staff resulted in Licensee unable to provide care and supervision necessary to meet Client needs as required by Title Twenty-Two 81078 and 81065.6. Although the allegation may be valid, based on statements and document reviews, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.

Report left.
No citations issued today.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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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