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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801728
Report Date: 10/09/2023
Date Signed: 10/24/2023 09:54:31 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
09/07/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230907134539
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:
10/09/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dinette ThompsonTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Dinette Thompson and discussed the disposition. During the course of this investigation statements were taken from witnesses, documents were obtained and reviewed, as well as site visits made to the facility where C1 was observed. The following determinations are made: On or about 9/1/2023, C1 was observed to have bruises on C1's body, arms and legs; C1 is essentially non verbal and unable to report as to the mechanism or origin of the injuries; No witnesses to any incidents that may have caused the bruising have been identified; No evidence suggesting the bruises are the result of staff abuse or neglect was found. Although the allegation that C1 sustained unexplained injuries while in care may be true, based upon the statements taken and documents reviewed, there is not a preponderance of evidence to prove or disprove the allegation. Therefore, the allegation is UNSUBSTANTIATED.
Report left.
No citations issued today. *****This is an amended version of original document******
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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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