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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803251
Report Date: 03/21/2024
Date Signed: 03/21/2024 12:24:35 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
01/12/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240112133609
FACILITY NAME:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Leonida LacapTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure resident was provided proper nutrition.
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, statements were taken, documents reviewed, and site visits were made to the facility. The following determinations are made: Complainant alleges R1 does not receive proper nutrition and has lost weight as a result; Complainant alleges R1 states the Administrator yells at R1; Complainant has no direct knowledge of R1's personal rights status; R1 refuses food prepared by facility staff and chooses to eat a restricted diet of mostly organic fruit; Other residents interviewed by this Department have not confirmed R1's allegations regarding personal rights violations; Site visits to facility show a well stocked kitchen with plenty of fresh and non perishable food meeting or exceeding regulations; Professional case worker familiar with R1 and the facility indicates R1 makes contradictory statements about R1's care and has observed the staff to make every effort to accommodate the needs of R1. Although the allegations may be true, or valid, based upon the statements; documents and site visits, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left.
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: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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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