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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 480109899
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:09:32 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
04/01/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250401131308
FACILITY NAME:HARRISON HOME CAREFACILITY NUMBER:
480109899
ADMINISTRATOR:HARRISON, WILMAFACILITY TYPE:
735
ADDRESS:390 SAWYER STREETTELEPHONE:
(707) 643-4853
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mario Gray, HousemanagerTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility mismanaging client's funds
INVESTIGATION FINDINGS:
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Licensing Program Analyst Magdaleno arrived unannounced to deliver findings regarding the above-mentioned complaint allegation and met with Mario Gray, Housemanager.

Complaint alleges that staff is holding clients personal and incidentals (P&I) check, only giving them small amounts now and then. Interview with staff indicated that they did cash client’s check for them and gave small amounts at a time in an effort to help client manage their funds.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.
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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 3
Control Number 21-AS-20250401131308
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: HARRISON HOME CARE
FACILITY NUMBER: 480109899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2025
Section Cited
CCR
80026(i)(3)
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80026(i)(3) Safeguards for Cash Resources, Personal Property, and Valuables of Residents Immediately upon admission of a client, all of his/her cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank…3)The licensee shall provide access
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Facility to submit self-certification that they understand the regulation cited and will not hold cash resources unless a bond is present.
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to the cash resources upon demand by the client or his/her authorized representative. Based on interviews, the licensee did not comply with the section cited above by not providing C1 cash when requested which posed a potential personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
04/01/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250401131308

FACILITY NAME:HARRISON HOME CAREFACILITY NUMBER:
480109899
ADMINISTRATOR:HARRISON, WILMAFACILITY TYPE:
735
ADDRESS:390 SAWYER STREETTELEPHONE:
(707) 643-4853
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mario Gray, HousemanagerTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff hit client
INVESTIGATION FINDINGS:
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Licensing Program Analyst Magdaleno arrived unannounced to deliver findings regarding the above-mentioned complaint allegation and met with Mario Gray, Housemanager.

Complaint alleges that staff hit client in care, stating that client was observed with a black eye. CCL staff did not observe evidence of a black eye. Per interviews, there were no witnesses to the alleged incident and involved parties denied during interviews that client was hit.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3