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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800782
Report Date: 06/15/2020
Date Signed: 06/15/2020 04:00:03 PM



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
03/02/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200302163320
FACILITY NAME:D HILLSIDE PLACE IIFACILITY NUMBER:
486800782
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:103 MICHAEL CT.TELEPHONE:
(707) 552-7584
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
06/15/2020
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Johnny CoperoTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the above captioned allegations. Licensing Program Analyst (LPA) A. Canela spoke with Licensee/Administrator, Johnny Copero, this date, for the purpose of delivering findings by phone due to the COVID – 19 precautions.

LPA previously reviewed records and received statements. It was alleged facility staff handled resident in a rough manner. It was alleged staff, S2 grabbed resident R1 inappropriately from underneath the arms and on another occasion dragged R1 out of the kitchen to the living room and kept kicking R1's legs up, so R1 could not stop the wheelchair. LPA interviewed staff and staff disclosed they have never handled any resident in a rough manner. Residents interviewed stated staff are very respectful and have not seen staff being inappropriate. LPA received a statement from R1 who did not provide any additional information on when incident may have occurred or if there were any witnesses.

Continue report see LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
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
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
03/02/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200302163320

FACILITY NAME:D HILLSIDE PLACE IIFACILITY NUMBER:
486800782
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:103 MICHAEL CT.TELEPHONE:
(707) 552-7584
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
06/15/2020
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Johnny CoperoTIME COMPLETED:
03:08 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yells at residents.
Home is not at a comfortable temperature.
INVESTIGATION FINDINGS:
1
2
3
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5
6
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9
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12
13
The Department conducted a complaint investigation regarding the above captioned allegations. Licensing Program Analyst (LPA) A. Canela spoke with Licensee/Administrator, Johnny Copero, this date, for the purpose of delivering findings by phone due to the COVID – 19 precautions.
LPA previously reviewed records and received statements. It was alleged facility staff yells at residents. It was corroborated by residents that staff do not yell at residents and R1 disclosed to LPA staff did not yell at him. It was also disclosed to LPA that there has been disagreements between R1 and R2 and R1 has yelled at the staff and R2. Residents interviewed disclosed the home is at a comfortable temperature. R1 disclosed he was provided an extra blanket when it was cold in the winter but had no other comments regarding the temperature. Visitors interviewed expressed the home has always been at a comfortable temperature and not cold when they visit.

The Department has investigated the above allegations and have found that the complaint is UNFOUNDED, meaning that the allegations are false, could not have happened, and/or are without a reasonable basis. Therefore, the complaint is Dismissed.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20200302163320
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: D HILLSIDE PLACE II
FACILITY NUMBER: 486800782
VISIT DATE: 06/15/2020
NARRATIVE
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LPA received a statement from R1's family member who expressed R1 has never disclosed staff being inappropriate with R1 and they are in communication with licensee.

The Department has investigated the above allegation and determined, 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.

This report was emailed to facility to obtain signature.

No citations issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3