216804130-2-18-2025-21-AS-KMOA-DE9MY3-20250226090048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804130
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:01:29 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
02/10/2025 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20250210171430

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:	02/18/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jade Dolcini, Program Manager		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility is not clean, safe, sanitary and in good repair

Facility not sufficiently staffed

INVESTIGATION FINDINGS:

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On 02/18/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating a complaint investigation regarding the above complaints and delivering complaint findings. LPA arrived and met with Program Manager, Jade Dolcini. During the investigation, LPA conducted interviews with staff and made observations.

Compliant alleges, Facility is not clean, safe, sanitary and in good repair. Report was received 02/10/2025, alleged onsite laundry has not had a dryer in over 3 weeks. Facility has no staff that clean the bathrooms, beddings, or common space areas. Facility has hanging cords from blinds. Fencing has rusted barbwire that could result to self-harm. Carpets are stained.

Based upon department interviews with staff and observations, information provided was contradicting with a lack of corroborating evidence to support the allegation. LPA and Program Manager toured the buildings and ground.
continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

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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Control Number 21-AS-20250210171430

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AVERY LANE	FACILITY NUMBER: 216804130
	VISIT DATE: 02/18/2025

NARRATIVE

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During the tour of the physical plant, LPA observed the facility to have two working dryers. Per conversation with Program Manager, facilities dryers had stopped working a few weeks ago. Facility had an issue with loading truck getting up the steep hill to deliver the new dryers, because of this the delivery was delayed. Since then, facility has got new dryers and are currently working. LPA observed facility to have non-hazardous items within title 22 regulations. LPA observed bathrooms, bedding, and common spaces to be clean and sanitary per title 22 regulations. LPA observed fencing to have barb wire and was located on the opposite side of the fence, on facilities neighbor’s property. Per facilities fire clearance emergency exits, they are non-hazardous and free of obstructions per title 22 regulations. LPA observed carpets to be stained. Per conversation with Program Manager, facility is currently under construction to add additional rooms and has plans to rip out the carpets and add new flooring. Per conversation with Program Manager, facility will notify LPA when they start the process of new flooring construction.

Compliant alleges facility is not sufficiently staffed.

Based upon department interviews with staff and document reviews, information provided was contradicting with a lack of corroborating evidence to support the allegation. LPA reviewed documents, made observations, and made interviews. Facility was staffed sufficiently per title 22 regulations.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC9099 (FAS) - (06/04)

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