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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803802
Report Date: 02/04/2022
Date Signed: 02/04/2022 01:21:03 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
04/15/2021 and conducted by Evaluator Katrina Walters
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210415120822
FACILITY NAME:NORTH STAR #1FACILITY NUMBER:
486803802
ADMINISTRATOR:BAIO, AMELIAFACILITY TYPE:
738
ADDRESS:5939 PLEASANTS VALLEY RDTELEPHONE:
(916) 869-8834
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:5CENSUS: DATE:
02/04/2022
UNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Facility BCBA, David LopezTIME COMPLETED:
01:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to protect the personal rights of client C1
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Katrina Walters arrived unannounced at this facility for the purpose of delivering findings for a complaint investigation regarding the above allegations and was greeted by Facility BCBA, David Lopez. At the time of this inspection there were 5 staff providing care and supervision for clients 5 in care.

On April 15, 2021, the Department received a complaint alleging: that staff failed to protect the personal rights of client C1. Information was obtained from record reviews and interviews. The investigation revealed that there was differing information from interviewed parties. LPA was unable to identify anyone that witnessed the allegation and there was insufficient information to prove the allegation occurred. Based on interviews, and review of information obtained, the investigation has revealed that the allegation of personal rights are unsubstantiated.
Continued on to 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 2
Control Number 21-AS-20210415120822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NORTH STAR #1
FACILITY NUMBER: 486803802
VISIT DATE: 02/04/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are Unsubstantiated.

No deficiencies cited.

Exit interview conducted.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2