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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803662
Report Date: 01/06/2022
Date Signed: 01/07/2022 10:34:16 AM

Substantiated


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
11/05/2021 and conducted by Evaluator Karen Lopez
COMPLAINT CONTROL NUMBER: 21-AS-20211105152524
FACILITY NAME:PEACH HUB, THEFACILITY NUMBER:
486803662
ADMINISTRATOR:GARCIA, JIM BERNARD PFACILITY TYPE:
775
ADDRESS:380 PITTMAN ROADTELEPHONE:
(707) 389-2403
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:45CENSUS: 29DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jim Garcia, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility issued an unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lopez arrived at this facility unannounced to deliver findings for the above allegations. Day program has been set remote due to high COVID cases in community and staff also work remote. Administrator, Jim Garcia arrived to facility and met with LPA.

LPA conducted complaint investigation on the allegation regarding unlawful eviction. LPA requested documentation. LPA and Licensing Program Manager (LPM) met with Administrator, Jim Garcia on 11/1/21 for a virtual informal meeting to discuss the eviction notice given to client (C1). Administrator stated that facility had given an eviction notice to C1. Per Administrator, C1 was given a 30-day eviction due to ongoing unresolved complaint with C1’s responsible party. There was an incident that occurred on June 16th, 2021 involving C2’s responsible party that made racial comments that were made during a Zoom class. LPA obtained the eviction notice for client that stated the incidents that have occurred that involved the responsible party and not C1. According to the eviction letter, C1’s responsible party demanded the facility to discontinue the pairing of C1 and C2.

Continue to LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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 5
Control Number 21-AS-20211105152524
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: PEACH HUB, THE
FACILITY NUMBER: 486803662
VISIT DATE: 01/06/2022
NARRATIVE
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On 8/24/21 staff 1 (S1) mentioned similar racial comments that C1’s responsible party had stated. C1’s responsible party demanded that S1 be removed from working with C1. Client 30-day eviction notice was given on September 9th, 2021. Per regulation 80068.5 the eviction notice was not given in support of the list following reasons: (1) Nonpayment of the rate for basic services within ten days of the due date. (2) Failure of the client to comply with state or local law after receiving written notice of the alleged violation. (3) Failure of the client to comply with general facility policies that are documented in the facility admission agreement, and are for the purpose of making it possible for clients to live together. (4) Inability to meet the client's needs. (A) Needs and Services Plan modification must have been performed, as specified in Section 80068.3(a), which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate as specified in Section 80068.3(b). (5) The client refuses to comply with his/her Restricted Health Condition Care Plan, if any, as specified in Section 80092.2. (6) Change of use of the facility. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator, Jim Garcia and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/05/2021 and conducted by Evaluator Karen Lopez
COMPLAINT CONTROL NUMBER: 21-AS-20211105152524

FACILITY NAME:PEACH HUB, THEFACILITY NUMBER:
486803662
ADMINISTRATOR:GARCIA, JIM BERNARD PFACILITY TYPE:
775
ADDRESS:380 PITTMAN ROADTELEPHONE:
(707) 389-2403
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:45CENSUS: 29DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jim Garcia, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lopez arrived at this facility unannounced to deliver findings for the above allegations. Day program has been set remote due to high COVID cases in community and staff also work remote. Administrator, Jim Garcia arrived to facility and met with LPA.

LPA conducted complaint investigation on the allegation regarding personal rights. There was an incident that occurred on June 16th, 2021 involving client 1 (C1) responsible party that made racial comments that were made during a Zoom class. This incident was raised by C2’s responsible party to facility and facility failed to become transparent with all staff to become aware of issues arising. On 8/24/21 staff 1 (S1) mentioned similar racial comments that C1’s responsible party had stated. During virtual Informal Meeting that took place on 11/1/21, Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) met with Administrator Jim Garcia. Administrator agreed that facility had not become transparent with staff about the racial comments that were said during Zoom which led to reoccurrence of incident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20211105152524
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: PEACH HUB, THE
FACILITY NUMBER: 486803662
VISIT DATE: 01/06/2022
NARRATIVE
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During investigation, there was not a preponderance evidence that the racial comments were directed towards C2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20211105152524
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: PEACH HUB, THE
FACILITY NUMBER: 486803662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2022
Section Cited
CCR
80068.5(a)
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80068.5 (a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons:...(1-6) (1) Nonpayment of the rate for basic services within ten days of the due date.
(2) Failure of the client to comply with state or local law after receiving written notice of the alleged violation. (3) Failure of the client to comply with general facility policies that are documented in the facility admission agreement, and are for the purpose of making it possible for clients to live together. (4) Inability to meet the client's needs. (A) A Needs and Services Plan modification must have been performed, as specified in Section 80068.3(a), which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate as specified in Section 80068.3(b). (5) The client refuses to comply with his/her Restricted Health Condition Care Plan, if any, as specified in Section 80092.2. (6) Change of use of the facility. This has not been met as evidence by:
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Facility will submit a statement that facility will comply with regulation 80068.5 (a) by 1/11/22.
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LPA received documentation and interviews. Facility gave C1 a 30-day eviction notice with reasons that did not comply with regulation 80068.5 (a).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5