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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801728
Report Date: 03/07/2023
Date Signed: 03/07/2023 10:06:26 PM

Substantiated


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
02/28/2023 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230228101122
FACILITY NAME:GLAJAN CARE, INC.FACILITY NUMBER:
486801728
ADMINISTRATOR:MILES, GLADYSFACILITY TYPE:
735
ADDRESS:163 DEVONSHIRE ST.TELEPHONE:
(707) 656-6012
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Keith Cooper, Assistant AdministratorTIME COMPLETED:
05:11 PM
ALLEGATION(S):
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Facility staff called client an inappropriate name.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced for the purposes of opening the above investigation for complaint number 21-AS-20230228101122. LPA toured the facility, made observations and took statements. Keith Cooper, Assistant Administrator arrived towards end of visit.

It was alleged facility staff called client an inappropriate name. Investigation revealed, there was an SOC341 mandated report received by Community Care Licensing (CCL). LPA conducted interviews and received corroborating information, related to the SOC341, that on 2/28/2023 during a visit by North Bay Regional Center (NBRC), Service Coordinator (SC1); it was observed/heard when Glajan Care Facility staff S1, directly called client C1 an "asshole" in the presence of SC1.
Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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
Control Number 21-AS-20230228101122
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: GLAJAN CARE, INC.
FACILITY NUMBER: 486801728
VISIT DATE: 03/07/2023
NARRATIVE
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Based on LPA’s investigation, corroborating statements received and staff S1 acknowledging the statement was made, although they stated it was not necessarily that they meant to call client C1 an inappropriate name, they did reference an inappropriate word toward C1. The preponderance of evidence standard has been met, therefore, allegation for, "Facility staff called client an inappropriate name" is found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20230228101122
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: GLAJAN CARE, INC.
FACILITY NUMBER: 486801728
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee to send in written statement they understand regulation an how they will ensure clients personal rights are not violated. In addition, facility to provide staff training on personal rights, client rights and mandated reporting.
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This requirement was not met, as evdenced by: Based on investigation & acknowledgement by staff S1. Staff violated C1's personal rights when they used innapropriate language towards client. This is a immediate health & safety risk to clients in care.
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Written statement POC due on 3/9/23 for written statement and staff training POC due by 3/17/2023 to CCL, attention LPA Araceli Canela.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3