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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803852
Report Date: 10/20/2023
Date Signed: 10/20/2023 09:37:27 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, 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
09/28/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230928092636
FACILITY NAME:THRIVE ADULT RESIDENTIAL CARE II, INC.FACILITY NUMBER:
486803852
ADMINISTRATOR:MARIA GOLITZENFACILITY TYPE:
735
ADDRESS:2340 CABOT CTTELEPHONE:
(510) 689-4911
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 3DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David SalamidaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Personal Rights Violation
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. LPA met with care staff and discussed the disposition. It has been alleged that S1 has violated the personal rights of 2 clients in care by making derogatory statements and directing expletives to them along with unwanted physical contact. S1 denies the allegations. Both clients have made consistent statements about the allegations and a staff/witness has confirmed being told similar reports from the clients. Facility Management has taken corrective measures with S1 in response to their own investigation. Based upon the statements made, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report Left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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-20230928092636
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: THRIVE ADULT RESIDENTIAL CARE II, INC.
FACILITY NUMBER: 486803852
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Cleared at time of visit. Administration has removed S1 from the facility and is requiring S1 to attend additional personal rights training.
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 **Based on statements, this requirement not met as evidenced by: S1 made abusive statements and unwanted physical contact with two clients in care. This posed an immediate violation of personal rights.
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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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2