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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804130
Report Date: 08/19/2025
Date Signed: 08/19/2025 09:57:48 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
08/15/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250815083854
FACILITY NAME:AVERY LANEFACILITY NUMBER:
216804130
ADMINISTRATOR:HILDEBRAND, CAMILLEFACILITY TYPE:
772
ADDRESS:200 ATHERTON AVETELEPHONE:
(415) 686-6127
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY:10CENSUS: 8DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jade Dolcini, Program DirectorTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff did not ensure facility was clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and delivered findings regarding the allegation listed above. LPA was greeted by staff who contacted Program Director, Jade Dolcini that arrived shortly after.

During investigation LPA made observations, reviewed documents and conducted interviews.
Complainant alleges the facility to be very dirty, e.g., floors not swept or mopped, dirty surfaces, chairs, and carpets, bathrooms not cleaned. As well the shower full of hair balls and to have dirty band aids. Photos were obtained by LPA, although it was difficult to determine based on the photos the level of cleanliness. On 8/19/2025 LPA toured facility to open complaint investigation and observed the (4) client bathrooms to be clean and sanitary. On 7/31/2025 & 8/5/2025 LPA Hansen conducted annual inspection of facility and did not observe showers with band aids or full of hair balls. Carpets were observed to be clean although some areas stained.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 2
Control Number 21-AS-20250815083854
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: 08/19/2025
NARRATIVE
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Continued from LIC9099

Investigation of complaint 21-AS-20250210171430 revealed Program Director indicated facility has future plans to replace carpets and add new flooring, and notify LPA when they start the process of new flooring construction (Unsubstantiated). In June 2025 facility added additional rooms and increased facility capacity. Today’s conversation with Program Director revealed they use to have a third-party cleaning company in every 2 to 3 weeks but about a year ago hired an in house staff who cleans all of the companies facilities and the facility carpet was replaced in mid April this year. As well, night shift staff preform cleaning and clients have chores as well. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not ensure facility was clean is UNSUBSTANTIATED

A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2