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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800888
Report Date: 06/11/2020
Date Signed: 06/11/2020 10:24:27 AM



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
10/07/2019 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20191007164759
FACILITY NAME:MED RESIDENTIAL CARE HOME IIFACILITY NUMBER:
486800888
ADMINISTRATOR:VERANO, MATILDAFACILITY TYPE:
740
ADDRESS:1243 GRANADA ST.TELEPHONE:
(707) 552-8550
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: DATE:
06/11/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Matilda VeranoTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff behavior poses as a risk to resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst Leibert has investigated the above captioned complaint allegation. LPA met with Administrator, Matilda Verano, this date for the purpose of delivering the findings. The visit was conducted as a televisit due to the COVID - 19 precautions. Complainant alleges that S1 struck R1 several times on the face with a closed fist on or about March 16, 2019. The allegation is denied. This Department has interviewed staff and witnesses; reviewed and obtained records and made the following determinations: Medical records for R1 indicate that R1 had substantial memory deficits and was often confused; Facility staff report that it was not uncommon for R1 to falsely report staff abuse when being repositioned or bathed; No signs of trauma, such as swelling or redness of the skin, was observed by staff or witness/Complainant following the alleged abuse in March; The responsible party for R1 states that R1 received excellent care at the facility and does not believe that R1 was abused in any way when in residence at the facility. This Department did not find any evidence to support the allegation of staff behavior posing a risk to R1. Therefore, we have found the complaint to be UNFOUNDED, meaning the allegation is false, could not have happened, or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
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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