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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236803358
Report Date: 04/07/2022
Date Signed: 04/07/2022 09:45:53 AM

Substantiated


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
04/01/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220401101754
FACILITY NAME:HOLY SPIRIT RESIDENTIAL CARE HOME INC. IIFACILITY NUMBER:
236803358
ADMINISTRATOR:GONZALEZ, PERLAFACILITY TYPE:
740
ADDRESS:1275 ELM STREETTELEPHONE:
(707) 972-5831
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 6DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Perla GonzalezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility doors are in disrepair.
INVESTIGATION FINDINGS:
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At approximately 08:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility, unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Perla Gonzalez and toured the facility. During the tour, LPA observed the main entry, inside door handle was removed. Upon further investigation, a residents bedroom exit door was in the same condition. An immediate civil penalty is being assessed in the amount of $1000.00, for this repeated violation in a 12 month period. LPA discussed with Administrator the importance of keeping the door handles in place and finding other ways to redirect exit seeking behavior.
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.
This report was reviewed with Administrator and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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-20220401101754
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: HOLY SPIRIT RESIDENTIAL CARE HOME INC. II
FACILITY NUMBER: 236803358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited
CCR
87203
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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met
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Licensee will develop a care plan to address exit seeking behavior, without violating regulation and what staff will do to keep residents engaged. Door handles were reinstalled during visit.
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as evidenced by: Based on LPA observation, Licensee removed the inside door handles of 2 exit doors. This poses an Immediate Safety risk to residents in care.
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Plan to be submitted to CCL by POC date of 04/15/2022.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
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