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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803740
Report Date: 05/13/2025
Date Signed: 05/13/2025 02:23:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
03/03/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250303171714
FACILITY NAME:KALUSUGAN HOMES - BOXWOODFACILITY NUMBER:
486803740
ADMINISTRATOR:LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
735
ADDRESS:2592 BOXWOOD LANETELEPHONE:
(707) 439-1816
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Annabelle Lewis-Barreto, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not assisting resident with grooming as needed
Staff are not assisting with resident communicating needs
INVESTIGATION FINDINGS:
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On 05/13/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 2 21-AS-20250303171714 investigation findings regarding the above allegations and met with Annabelle Lewis-Barreto, Licensee. Reporting Party (RP) alleges that facility staff are not assisting Client 1 (C1) with grooming as needed resulting in nails that C1 scratched themselves with, and staff are not assisting with C1 communicating needs via American Sign Language (ASL), Facetime, and Zoom.

LPA Florio conducted 10-day complaint investigation visit on 03/04/2025 and obtained documents, made observations, and conducted interviews. Based on interviews with staff and documents and photos obtained, LPA received conflicting information which revealed that C1 is not proficient in ASL, the facility has a recurring weekly Zoom meeting scheduled for C1 to communicate with friends, and the facility has a nurse who comes to the facility regularly to cut C1’s nails as not to cause injury due to the physical limitations of C1.

Continued on LIC9099...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 2
Control Number 21-AS-20250303171714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KALUSUGAN HOMES - BOXWOOD
FACILITY NUMBER: 486803740
VISIT DATE: 05/13/2025
NARRATIVE
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Continued on LIC9099C...

On 4/14/2025, LPA received further conflicting information from the facility Licensee, such as pictures, logs, and forwarded email communications, which indicate that C1 is not proficient in ASL, and that staff assist with C1’s weekly scheduled Zoom calls. Additionally, on 05/12/2025, LPA conducted a phone interview with C1’s North Bay Regional Center (NBRC) service coordinator who provided conflicting information regarding both allegations. The service coordinator states the observed marks on C1's face appear to be acne rather than scratches and during quarterly visits to C1’s day program and care home, the service coordinator conducted interviews that revealed that C1 is not observed scratching. Furthermore, Service Coordinator states that NBRC sent a sign language consultant interpreter to the care home to conduct an ASL evaluation of C1’s abilities on 08/30/2023 and the notes obtained from NBRC state the results of this evaluation were that C1 is not proficient in ASL.

Based on record review, interviews conducted, and observations made, the allegations listed above are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited.

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

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
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