216804278-1-14-2026-21-AS-VBEI-DQJNBV-20260121091943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804278
Report Date: 01/14/2026
Date Signed: 01/14/2026 12:54:27 PM

Substantiated

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
08/18/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20250818104207

FACILITY NAME:	ROSEBAY BEHAVIORAL HEALTH		FACILITY NUMBER:	216804278
ADMINISTRATOR:	LITCHFIELD, CHARLES		FACILITY TYPE:	772
ADDRESS:	200 VALLEY VIEW AVENUE		TELEPHONE:	(562) 916-6488
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	6	CENSUS: 6	DATE:	01/14/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Members, Brandon Kwok and Jacob Simon, Administrator, Charlie Litchfield		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff did not follow Physicians orders
Staff did not allow resident to return to facility

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations, and met with Staff Members, Brandon Kwok and Jacob Simon. Administrator, Charlie Litchfield, arrived during visit at approximately 9:45AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations, “Staff did not follow physician’s orders, and Staff did not allow resident to return to facility.” Complaint alleged that facility staff did not follow the physician’s orders for Client 1’s (C1) clonazepam and that staff were offering them pills every 2 hours. Complaint also stated that after C1 was discharged from a behavioral crisis center, the facility refused to let C1 return to the facility.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

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 5

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
08/18/2025 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20250818104207

FACILITY NAME:	ROSEBAY BEHAVIORAL HEALTH		FACILITY NUMBER:	216804278
ADMINISTRATOR:	LITCHFIELD, CHARLES		FACILITY TYPE:	772
ADDRESS:	200 VALLEY VIEW AVENUE		TELEPHONE:	(562) 916-6488
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	6	CENSUS: 6	DATE:	01/14/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Members, Brandon Kwok and Jacob Simon, Administrator, Charlie Litchfield		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff are not trained properly to meet residents needs
Staff did not allow resident to leave the facility

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegations, and met with met with Staff Members, Brandon Kwok and Jacob Simon. Administrator, Charlie Litchfield, arrived during visit at approximately 9:45AM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegations, “Staff are not trained properly to meet residents needs and “Staff did not allow resident to leave facility.”
There is an allegation that “staff are not properly trained to meet resident needs.” Complaint alleged that staff at the facility advertised that their program has mental health counselors 24 hours/7 days a week and services to meet C1’s needs. Complaint alleged that during C1’s stay, C1 did not have mental health services provided and feels that the facility misrepresented themselves.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20250818104207

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: ROSEBAY BEHAVIORAL HEALTH	FACILITY NUMBER: 216804278
	VISIT DATE: 01/14/2026

NARRATIVE

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Continued from LIC9099A

LPA reviewed 9 staff files consisting of 1 Clinical Director, 1 Nurse, 1 Therapist, and 6 Behavioral Health Technicians. Review of staff files showed that 9 of 9 staff files had proof of new orientation training completed timely as required by Title 22 regulations.

There is an allegation of “Staff did not allow resident to leave facility.” Information provided by complainant stated that C1 wanted to self-discharge themselves from the facility and the facility wouldn’t allow them to leave. Interview conducted with Chief Operating Officer (COO) revealed that on May 11, 2025, C1 had been yelling, screaming, and was emotionally deregulated. Per COO, they contacted San Rafael Police Department (SRPD) because C1 had been screaming and hitting themselves with a plastic cup causing their forehead to become swollen and form a bruise. Per COO, C1 required one-on-one supervision which couldn’t be provided as C1 wanted to stay outside to smoke and be on their phone and they needed staff to be inside the house to supervise other clients. C1 asked to go for a walk but SRPD told C1 to either stay at the house or go to the hospital. C1 was taken to the hospital where they were placed on a 5150 hold. Review of Facility’s House Rules stated that clients who participate in the program “must remain on the property grounds unless accompanied by a staff member. Leaving the property is prohibited and may result in staff contacting local authorities and/or discharge from the program.”

Based on interviews conducted, record review, and observations made, these allegations are Unsubstantiated.

A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20250818104207

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: ROSEBAY BEHAVIORAL HEALTH	FACILITY NUMBER: 216804278
	VISIT DATE: 01/14/2026

NARRATIVE

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Continued from LIC9099

There is an allegation of “Staff did not follow physician’s orders.” Review of C1’s medication orders stated the following: Clonazepam, 1mg tablet every 2 hours; 1-2 tablets anytime of day, all at once or separately. Max 2 tabs per day. Review of C1’s electronic medication authorization record (EMAR) showed that C1 was administered 1 tablet of clonazepam at 8:09PM on 05/09/2025 and at 6:15PM on 05/11/2025. Further review of C1’s Electronic Medication Authorization Record (EMAR) and facility documents showed that on 5/10/2025, C1 was administered 1 tablet of clonazepam at 7PM and 2 tablets of clonazepam at 10:11PM, which exceeded the maximum dose allowed per physician orders.

There is an allegation of “Staff did not allow resident to return to facility.” Per complaint, after being discharged from a behavioral crisis center, C1 was told they could not return to the facility. Interview with Chief Operating Officer (COO) revealed that on May 11, 2025, C1 had been yelling, screaming, and was emotionally deregulated so the San Rafael Police Department (SRPD) was contacted. Per COO, they contacted SRPD because C1 had been screaming and hitting themselves with a plastic cup causing their forehead to become swollen and form a bruise. C1 was sent to the hospital and placed on a 5150 hold. Per COO, C1 required one-on-one supervision which couldn’t be provided as C1 wanted to stay outside to smoke and be on their phone and they needed staff to be inside the house to supervise. COO further stated that C1 was not allowed to return to the facility because they required a higher level of care due to them screaming and threatening to self-harm themselves adding that these behaviors made the environment unsafe for C1 and the other clients in the home. Per interview with the Clinical Director, C1 was not reassessed by facility once ready for discharge and facility refused to bring C1 back. C1 was not provided an eviction notice at the time of refusal. Interview with COO and review of facility documents showed that an eviction notice was not provided to C1.

Based on interviews conducted, record review and observations made, these allegations are Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20250818104207

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: ROSEBAY BEHAVIORAL HEALTH	FACILITY NUMBER: 216804278
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/15/2026 Section Cited CCR 81075(b)	1 2 3 4 5 6 7	81075 HEALTH-RELATED SERVICES:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: based on record review, Licensee did not ensure that Client 1 (C1) received their	1 2 3 4 5 6 7	Licensee to submit proof of medication training for all staff administering medication. Proof of training to be submitted by POC due date of 01/15/2026.
	8 9 10 11 12 13 14	medication per physician orders. This poses an immediate health/safety/personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 01/26/2026 Section Cited CCR 81068.5(a)	1 2 3 4 5 6 7	81068.5 EVICTION PROCEDURES: (a) The licensee shall be permitted to evict a client with 30 days' written notice for any of the following reasons...This requirement was not met as evidenced by: based on interviews and record review, Licensee did not ensure that C1 received a proper eviction	1 2 3 4 5 6 7	Licensee to conduct an in-service training with managerial staff reviewing Eviction Procedures. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date 01/26/2026.
	8 9 10 11 12 13 14	notice per regulation. This poses a potential health/safety/personal rights risk to clients in care.	8 9 10 11 12 13 14

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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC9099 (FAS) - (06/04)

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