486801821-10-10-2023-21-AS-KMOA-CWSLD3-20231020083914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801821
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:19:32 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
08/23/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230823164709

FACILITY NAME:	ANN'S CARE HOME		FACILITY NUMBER:	486801821
ADMINISTRATOR:	BEST, DEBRA ANN		FACILITY TYPE:	740
ADDRESS:	124 DELTA CIRCLE		TELEPHONE:	(707) 643-3363
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	5	CENSUS: 1	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Debra Ann Best		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Personal Rights Violation
Lack of Care and Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. LPA met with Debra Ann Best and discussed the disposition. It has been alleged that C1 reported having been struck and called derogatory names by staff and that, on more than one occasion, staff have not been available to receive R1 when returned to the facility by Day Care transportation staff. This investigation has included site visits; witness interviews and document reviews. The following determinations are made: C1 has medical and psychological history that suggests the allegations, if made, may not be reliable; In a recent, private interview,C1 stated satisfaction with the placement and denied staff abuse; There have been incidents when facility staff did not respond to transportation staff attempting to return C1 from Day Care which resulted in transportation staff returning C1 to Day Program; However, no evidence was found suggesting that C1 was without Care and/or Supervision at anytime since placement at the facility. Therefore, although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegations true or false. The complaint is UNSUBSTANTIATED.
Report left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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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