486800888-7-26-2024-21-AS-KMOA-D7XMNQ-20240808094555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486800888
Report Date: 07/26/2024
Date Signed: 07/26/2024 10:48:59 AM

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
05/03/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240503081442

FACILITY NAME:	MED RESIDENTIAL CARE HOME II		FACILITY NUMBER:	486800888
ADMINISTRATOR:	VERANO, MATILDA		FACILITY TYPE:	740
ADDRESS:	1243 GRANADA ST.		TELEPHONE:	(707) 552-8550
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	6	CENSUS: 5	DATE:	07/26/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Matilde Verano, Administrator		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to deliver findings regarding the above allegation on 7/26/2024.

It is alleged that staff at the facility are verbally abusive and mistreat Resident (R1).

LPA visited the facility on 05/03/2024: conducted interviews and made observations. LPA observed that R1, as well as the other residents in the facility were clean and their needs were being met. LPA observed staff caring for R1 and providing R1 assistance as needed. R1’s room was clean, their bed was made with required linens. LPA observed that the staff on duty addressed R1 respectfully and kindly. R1 stated to LPA that the staff treated them well and was respectful except for Staff (S1).

Continued on 9099-C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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-20240503081442

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: MED RESIDENTIAL CARE HOME II	FACILITY NUMBER: 486800888
	VISIT DATE: 07/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

.....Continued from 9099

LPA interviewed 3 of 5 residents. R2 and R3 stated that the staff never talked to them in any way that was disrespectful or abusive and they did not recall hearing the staff talk to other residents that way. R4 and R5 were sleeping but appeared clean and cared for.

LPA interviewed S1 via phone on 05/09/2024. S1 stated that R1 required a maximum of care due to R1’s size and ambulatory status. S1 stated they never referred to R1 or any other resident inappropriately.

Based on interviews, documents gathered and observations made, LPA was unable to determine the complainant’s allegation that their personal rights were being violated. 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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2