486803251-7-19-2023-21-AS-HDBI-CTWTTU-20230720150118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803251
Report Date: 07/11/2023
Date Signed: 07/19/2023 04:04:38 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
03/30/2023 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230330105350

FACILITY NAME:	MASONIC GUEST HOME II		FACILITY NUMBER:	486803251
ADMINISTRATOR:	LACAP, LEONIDA		FACILITY TYPE:	740
ADDRESS:	108 PINTO DRIVE		TELEPHONE:	(707) 644-3822
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Fermin Lagasca, facility manager		TIME COMPLETED:	05:14 PM

ALLEGATION(S):

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Personal Rights
Staff hit resident's
Staff is not following Admission Agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced for the purpose of delivering findings regarding the above allegations and met with care staff, Joyce Bernardo. Facility Administrator, Leonida "Lennie" Lacap, was not available and office manager, Fermin Lagasca arrived a few minutes later.

During the investigation, interviews were conducted with staff, residents and relevant parties. LPA made observations, and previously reviewed, requested records and received statements. It was alleged staff hit resident, more specifically that, staff(S2) popped resident R1 on their hand in frustration because R1's hands were trembling when S2 was trying to obtain a finger stick. S2 denies the allegations and state they never used their hands on R1 or any other resident. It was also alleged residents Personal rights are violated and S2 is mean to other residents and resident R3 was heard crying when staff had to change their diaper at night. Resident R3 was interviewed on different occasions by LPA, Canela and LPA, Nakagawa and R3 denied being yelled at or hit by staff.

Continue report see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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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Control Number 21-AS-20230330105350

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: MASONIC GUEST HOME II	FACILITY NUMBER: 486803251
	VISIT DATE: 07/11/2023

NARRATIVE

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Resident, R3 disclosed they like living at the facility, staff are helpful and nice and R3 does not need assistance changing their diaper at night and does it on their own. Other residents interviewed also disclosed, they like living at the home and staff are nice. They have not seen or heard staff yelling or hitting residents. Staff interviewed denied the allegations and explain that no one uses their hands on any residents and they treat them with respect.

It was also alleged that facility staff are not following the Admission Agreement in that resident R1 was asked by staff(S2)to pay an additional amount after R1 had won extra money at Bingo. R1 stated they did not pay the facility any additional money. LPA interviewed staff (S2&S3) who stated they never asked the resident for any additional payment. S3 stated they never ask the residents for any payment, they always go through their public guardian or responsible party if funds are due, but would never go directly to the resident and deny the allegations that they asked R1 for any additional funds.

Based on records reviewed, interviews conducted and additional statement received from outside individual where it was disclosed resident R1 stated living at the facility was not bad and expressed they wanted to move back to the facility. Although the allegation may be valid, there is not a preponderance of evidence to prove the allegation did or, did not, occur. Therefore, the above allegation for, Personal Rights; Staff hit resident's and Staff is not following Admission Agreement, are all UNSUBSTANTIATED.

No citations issued today.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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