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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803728
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:44:36 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, 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
05/26/2021 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20210526163559
FACILITY NAME:PALM VIEW RETREATFACILITY NUMBER:
486803728
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
735
ADDRESS:150 BROADWAY STREETTELEPHONE:
(707) 652-2624
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:32CENSUS: 19DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Cecily Palma, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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9
Questionable Death
Staff did not seek timely medical attention for resident in care
INVESTIGATION FINDINGS:
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On 9/29/2021 LPA Tobola conducted a complaint investigation visit to deliver findings to the facility and was greeted by Administrator, Cecily Palma. The Department conducted facility tour, record review and interviews with staff, clients and outside parties.

The complaint alleges that a questionable death of Client (C1) ocurred in the facility. Based on a tour of the facility and interviews with staff, clients and outside parties the Department was provided with conflicting statements from staff and clients pertaining to the allegation. In addition, the death was investigated by the Solano County Coroner's Office and determined C1 passed away due to natural causes. therefore the allegation is found to be unsubstantiated.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 4
Control Number 21-AS-20210526163559
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: PALM VIEW RETREAT
FACILITY NUMBER: 486803728
VISIT DATE: 09/29/2021
NARRATIVE
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The complaint alleges staff did not seek timely medical attention to Client (C1) in care. Based on a tour of the facility and interviews with staff, clients and outside parties, the Department was provided with conflicting statements regarding C1's whereabouts and staff unable to determine when medical attention was needed. In addition, Solano County Coroner's Office and determined C1 passed away due to natural causes, therefore the allegation is found to be unsubstantiated.

No deficiencies cited during today's visit. LPA provided Administrator with an email copy of the complaint report. Signatures on file and appeal Rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4