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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803525
Report Date: 11/06/2024
Date Signed: 11/06/2024 05:57:36 PM

Document Has Been Signed on 11/06/2024 05:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DARWIN FACILITYFACILITY NUMBER:
486803525
ADMINISTRATOR/
DIRECTOR:		HALL, MYRTLEFACILITY TYPE:
735
ADDRESS:1612 TUCSON CIRCLETELEPHONE:
(707) 426-4981
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 3DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Joanna Hall, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:54 PM
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On 11/06/2024, at approximately 2:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident visit to follow up on a SOC341 Report of Suspected Abuse and an Incident Report. LPA communicated with facility staff and was told they just left to pick up the clients and would be back in 30 minutes.

At approximately 2:45 PM, House Manager, Joanna Hall arrived with 3 clients. LPA explained the reason for the visit was to investigate an incident which occurred on 10/30/2024 and was reported directly to LPA by Daniel Morris, Service Coordinator with North Bay Regional Center (NBRC) on 11/5/2024. House Manager stated they sent the reports to CCL, but upon further investigation, it was revealed that the reports were sent to the old CCL email address. Ultimately, the reports were not received by the department until NBRC contacted LPA. The reports state that Client 1 (C1) alleges that they were struck by Staff 1 (S1). C1's story changed from initially occurring in the doctor's office (UC Davis Medical Center, where S1 was attending an appointment) to it occurred in the car. In LPA's interview with C1, they stated that they were struck twice; once in the doctor's office and once in the car, both with a closed fist.

LPA made observations, obtained documentation, and conducted interviews. LPA informed House Manager that they shall report such incidents to local law enforcement and the local ombudsman within 24 hours of the incident. House Manager contacted local law enforcement during today's visit and a report was filed. House Manager agreed to contact the local Ombudsman first thing tomorrow morning.

At approximately 4:54 PM, Suisun City Police arrived to take a report. They stated further investigation is needed and they will attempt to retrieve camera footage from the doctor's office at UC Davis Medical Center.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DARWIN FACILITY
FACILITY NUMBER: 486803525
VISIT DATE: 11/06/2024
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Continued from LIC809...

LPA needs more time to conduct interviews and investigate the incident and will follow up with facility.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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