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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800791
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:00:17 PM

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
10/24/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20221024171225
FACILITY NAME:ZINA'S CARE HOME IIFACILITY NUMBER:
486800791
ADMINISTRATOR:ZINA LEEFACILITY TYPE:
735
ADDRESS:2112 ALLSTON PLACETELEPHONE:
(707) 432-1312
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 4DATE:
11/18/2022
UNANNOUNCEDTIME BEGAN:
07:19 AM
MET WITH:Staff Member #2, Mary Foster BrownTIME COMPLETED:
07:20 AM
ALLEGATION(S):
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Staff hit client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Zina's Care Home II unannounced for the purpose of delivering complaint findings. LPA was greeted at the door by Staff Member #2, Mary Foster Brown, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, clients and various outside parties, including but not limited to responsible parties and witnesses. LPA reviewed training documents on November 7, 2022.

Complaint alleges that Staff hit client in care. Based on interviews that were conducted, LPA could not prove or disprove that the Staff hit client in care due to inconsistent statements made during the course of the investigation. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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-20221024171225
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: ZINA'S CARE HOME II
FACILITY NUMBER: 486800791
VISIT DATE: 11/18/2022
NARRATIVE
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A finding that the complaint allegation of Staff hit client in care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to Staff Member #2, Mary Foster Brown
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2