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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804033
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:12:41 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
10/30/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20241030105747
FACILITY NAME:SAKURA HOMEFACILITY NUMBER:
486804033
ADMINISTRATOR:JENNA BALUYOTFACILITY TYPE:
735
ADDRESS:2124 TILDEN PLACETELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Elinore Ramas, LicenseeTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Reporting Requirements not met
INVESTIGATION FINDINGS:
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13
On 02/20/2025, at approximately 11:45 AM, Licensing Program Analysts (LPAs) Julie Florio and Elias Magdaleno arrived unannounced to deliver findings for the above allegation. Reporting Party (RP) alleges that Facility did not report an incident to the Client 1's (C1's) responsible party.

LPA made initial contact via telephone with RP on 10/30/2024 at which time RP stated they did not have any additional information to add to the complaint investigation. LPA conducted 10-day investigation visit on 10/31/2024 and conducted interviews, made observations, and obtained documents. LPA was able to interview the Administrator and Staff 1 (S1). Clients were unable to be interviewed due to their intellectual disabilities. Subsequent interviews were conducted with Administrator, Staff 2 (S2), and Staff 3 (S3) on 02/13/2025. The interviews conducted and records reviewed provided conflicting information regarding the above allegation.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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-20241030105747
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: SAKURA HOME
FACILITY NUMBER: 486804033
VISIT DATE: 02/20/2025
NARRATIVE
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Conitnued from LIC9099...

Based on records review, Facility submitted a Special Incident Report for the incident which occurred on the evening of 10/26/2024 to Community Care Licensing Division (CCLD). The report was received by the Department on 10/28/2024. The client’s responsible party was informed of the incident upon arrival at the facility the following day, which is within the required reporting timeframe.

Based on interviews conducted, observations made, and record review, the allegations listed above are UNSUBSTANTIATED. A finding that 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 during visit.

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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2