286804070-7-20-2023-21-AS-KMOA-CU6NFF-20230728102529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804070
Report Date: 07/20/2023
Date Signed: 07/20/2023 10:46:00 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
05/23/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230523133149

FACILITY NAME:	AGING IN THE BAY 3		FACILITY NUMBER:	286804070
ADMINISTRATOR:	MENDAROS, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	1088 DONALDSON WAY		TELEPHONE:	(510) 388-7352
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS: 6	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Staff Member, Angelina Manabat		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Staff Member, Angelina Manabat.
Administrator, Charmaine Mendaros, was available by telephone. Administrator gave permission for Staff Member, Angelina Manabat, to sign the documents.

During the course of the Investigation, LPA made observations, reviewed documents, and conducted interviews. There is an allegation of Illegal Eviction. The Report received on 05/23/2023, stated that Resident 1 (R1) was dropped off at the Emergency Room on 05/22/2023 but did not require medical attention. The Report also stated that the Administrator would not take R1 back although R1 was paid through the end of May 2023, they “already filled the room.” Attempts to contact the Reporting Party for more information were unsuccessful. During visit conducted on 06/02/2023, the LPA observed R1 to be at the facility. Upon arrival, LPA introduced themselves to the residents and R1 told LPA their name.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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-20230523133149

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: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
	VISIT DATE: 07/20/2023

NARRATIVE

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Continued from LIC9099

During visit conducted on 07/20/2023, LPA observed R1 to still be residing at the facility. Interview conducted with Facility Administrator stated that R1 was taken to the hospital due to needing a medication refilled. There was a miscommunication with the Hospital Staff and the Facility Administrator regarding R1. Facility Administrator stated they agreed to have R1 temporarily move into the facility at the request of a Kaiser Social Worker. Facility Administrator stated that they have been working with multiple entities to find a facility more suitable for R1 due to their care needs. Facility Administrator informed LPA that they were not abandoning R1 and picked up R1 from the hospital. Facility Administrator stated that R1 will continue to live at the facility while the Administrator continues working with other entities regarding placement and R1’s Conservatorship.

Based on interviews conducted, records reviewed, and observations made, the allegation of Illegal Eviction is 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 and LIC811 (Confidential Names) discussed and provided to Staff Member. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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