216890070-9-23-2021-21-AS-HDBI-C75UR9-20210923154821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216890070
Report Date: 09/23/2021
Date Signed: 09/23/2021 09:43:32 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210702133802

FACILITY NAME:	HACIENDA HOME		FACILITY NUMBER:	216890070
ADMINISTRATOR:	ALFONSO, FERDINAND		FACILITY TYPE:	735
ADDRESS:	833 DESCANSO WAY		TELEPHONE:	(415) 491-0226
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 5	DATE:	09/23/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Direct Support Staff Member, Romulo Damasco		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Facility staff speak inappropriately to residents
Facility staff threatened resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hacienda Home for the purpose of delivering complaint findings. LPA met with Direct Support Staff Member, Romulo Damasco and was granted access into the home.

During the course of the investigation, LPA interviewed staff, clients and various outside parties, reviewed various documents including resident, staff and facility records.

Complaint alleges that facility staff speak inappropriately to residents and threaten residents. Based on interviews conducted, LPA was unable to identify any clients in care being spoken to inappropriately or being threatened in any way. LPA was unable to confirm any clients having spoken to anyone outside of the facility. In addition, the client does not know who any of the neighbors are.

(Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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-20210702133802

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HACIENDA HOME	FACILITY NUMBER: 216890070
	VISIT DATE: 09/23/2021

NARRATIVE

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LPA interviewed witnesses that reported no concerns with the facility, nor have they received concerns from clients in care. Based on review of records, LPA was unable to identify any documented incidents that occurred

Based on the interviews that were conducted and the documents reviewed, the allegations of, facility staff speak inappropriately to residents and threaten residents is Unsubstantiated. A finding that the complaint allegations of facility staff speak inappropriately to residents and threaten residents is unsubstantiated, meaning that 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 allegations are UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Ferdinand Alfonso.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC9099 (FAS) - (06/04)

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