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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803859
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:18:15 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
12/09/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221209145006
FACILITY NAME:CAREWELL AT RED PHEASANT, LLCFACILITY NUMBER:
486803859
ADMINISTRATOR:COLEMAN, MARIEFACILITY TYPE:
740
ADDRESS:219 RED PHEASANT DRTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maricris Salcedo, CarestaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision - staff are not sufficient to prevent resident from self-harm/self-mutalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Jill Nakagawa arrived unannounced for the purpose of delivering findings on this complaint. LPA discussed with Maricris Salcedo, Carestaff and Ron-Mark Adriano, House Manager, via phone the findings. It has been alleged that the staff are not sufficient to prevent resident R1 from self-harm/self-mutalization. During the course of this investigation site visits were made to the facility; statements were taken and documents obtained and reviewed. Based upon the statements and documents, the following determinations are made: R1 has not performed self-harm or self-mutilation while a resident at the facility. In addition, LPA found no evidence of R1 having access to inappropriate materials. Although the allegation may be true, based upon the records and statements, there is not a preponderance of evidence to prove that allegation did, or did not, happen. Therefore, the allegation is UNSUBSTANTIATED.



(Continued on 9099-A)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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
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
12/09/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221209145006

FACILITY NAME:CAREWELL AT RED PHEASANT, LLCFACILITY NUMBER:
486803859
ADMINISTRATOR:COLEMAN, MARIEFACILITY TYPE:
740
ADDRESS:219 RED PHEASANT DRTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maricris Salcedo, CarestaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision - Licensee failed to ensure RSO paperwork shows current address for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
(Cont. from 9099)

Licensing Program Analyst Jill Nakagawa arrived unannounced for the purpose of delivering findings on this complaint. LPA discussed with carestaff Maricris Salcedo, and Ron-Mark Adriano, House Manager, via phone the findings. It has been alleged that Licensee failed to ensure RSO (Registered Sex Offender) paperwork shows current address for resident.

During the course of this investigation site visits were made to the facility; statements were taken and documents obtained. Based upon the statements and documents, the following determinations are made: R1 nor DPOA disclosed to Licensee at any time that R1 was RSO with registration requirements, therefore the Department has found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2