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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801443
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:37:10 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
08/06/2024 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240806161716
FACILITY NAME:MASONIC GUEST HOMEFACILITY NUMBER:
486801443
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:310 MASONIC DR.TELEPHONE:
(707) 554-1432
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Leni Lacap, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Faciltiy staff are not meeting residents care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) A Canela arrived unannounced for the purpose of opening a complaint regarding the above allegation for Faciltiy staff are not meeting residents care needs.
During todays investigation, LPA made observations, took statements and reviewed documents. It was alleged R1 was found with ants in their diaper; Complainant had no direct knowledge or saw ants in R1's diaper but was made aware. LPA did not get any corroborating statements from staff or residents that were interviewed. LPA did not observe any ants in any rooms, but it was corroborated that the facility had ants in another residents room because of some food left in the room. Although the allegation may be true, or valid, based on LPAs observation and no corroborating statements received from resident or staff interviewed; there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation for Faciltiy staff are not meeting residents care needs is UNSUBSTANTIATED. Report emailed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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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