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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801788
Report Date: 11/17/2020
Date Signed: 11/18/2020 08:53:56 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
11/05/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20201105091708
FACILITY NAME:ALMABELLA MANOR IIFACILITY NUMBER:
486801788
ADMINISTRATOR:GUBA,ALMABELLAFACILITY TYPE:
740
ADDRESS:841 ROLEEN DRIVETELEPHONE:
(707) 315-4427
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 5DATE:
11/17/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Almabella GubaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Resident was shoved by staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator Guba this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele - visit due to the COVID - 19 precautions. Complainant alleges that a staff person shoved R1 to the floor during an incident that occurred at the facility on or about 10/11/20. The allegation is denied. This Department has reviewed records, including medical records, and taken statement from witness; staff and interested parties and has made the following determinations: R1 exhibited aggressive behaviors during the incident and was subdued by S1; Witnesses present state that S1 put arms around R1 and brought R1 to a sitting position in order keep R1 from self injurious behavior and property damage; Complainant claims to have been talking on the phone with R1 at the time and, having heard a scuffle, believes that R1 was shoved to the floor by S1; R1 has a medical diagnosis that would bring into question any statements made regarding the incident in question and would preclude taking R1's statement. While the allegation may be true, based upon records reviewed and statements, there is not a preponderance of evidence to proof the allegation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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
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
11/05/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20201105091708

FACILITY NAME:ALMABELLA MANOR IIFACILITY NUMBER:
486801788
ADMINISTRATOR:GUBA,ALMABELLAFACILITY TYPE:
740
ADDRESS:841 ROLEEN DRIVETELEPHONE:
(707) 315-4427
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: DATE:
11/17/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Almabella GubaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not fed sufficient amount of food
Resident is kept at facility by staff against resident's will
Staff took residents phone
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator Guba this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele - visit due to the COVID - 19 precautions. Complainant alleges that R1 is not feed sufficient amounts of food and that on 10/11/20 R1 was kept at the facility by staff against R1's will and that R1's phone was taken by staff. The allegations are denied. This Department has reviewed records, including medical records, and taken statement from witness; staff and interested parties and has made the following determinations: R1 was not interviewed regarding the allegations due to medical opinion that suggests it would be unreliable; Facility menus comply with Title twenty-Two regulations; Witness who have visited the facility report that the food service is excellent and plentiful; R1 has stated observing a "hunger strike" but usually can be persuaded to eat; R1 was not allowed to leave the facility to go with unauthorized persons without the consent of the Responsible Party who holds POA; one of the unauthorized persons is restrained by valid court order to stay away from R1; Claims that staff took R1's phone are denied by staff and, in fact, was taken by Responsible Party according to staff and the Responsible Party for the purpose of repairing or replacing it due to damage that occurred when R1 through the phone.
...............Continued on second page.............
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: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20201105091708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: ALMABELLA MANOR II
FACILITY NUMBER: 486801788
VISIT DATE: 11/17/2020
NARRATIVE
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Based upon records reviewed, including medical records, and statements taken from staff; witnesses; and interested parties, this Department has found that the allegations in the complaint are UNFOUNDED, meaning that the allegations are false, could not have happened, or are without a reasonable basis. The complaint is therefore dismissed.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3