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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800768
Report Date: 06/28/2024
Date Signed: 06/28/2024 02:13:49 PM

Unsubstantiated


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
05/24/2024 and conducted by Evaluator Julie Florio
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240524090931
FACILITY NAME:PENNSYLVANIA CARE HOMEFACILITY NUMBER:
486800768
ADMINISTRATOR:PUNZALAN, ELPIDIOFACILITY TYPE:
735
ADDRESS:2055 PENNSYLVANIA AVENUETELEPHONE:
(707) 438-0267
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 4DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Patricia Bucal, House ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights/ Staff do not treat resident with dignity and respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Julie Florio arrived unannounced at this facility to obtain additional documents, make observations, complete additional interviews, and deliver findings of above allegation. LPA met with Patricia Bucal, House Manager. LPA conducted 10-day on 5/31/2024 and obtained documents, made observations, and conducted interviews with House Manager, client (C1), and staff (S1).

Today, based on record review, interviews conducted, and observations made, the allegation of Personal Rights/Staff do not treat resident with dignity and respect is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED..

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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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