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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804040
Report Date: 02/15/2024
Date Signed: 02/15/2024 09:07:30 AM

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
01/30/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240130110131
FACILITY NAME:HAVEN CARE HOME LLCFACILITY NUMBER:
486804040
ADMINISTRATOR:GBY, ARMELLE MFACILITY TYPE:
735
ADDRESS:151 FORSYTHIA CTTELEPHONE:
(510) 395-3966
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:5CENSUS: 1DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Armelle GBYTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff violated clients personal rights
Staff locked client out of the house
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, site visits were made, as well as statements taken and documents reviewed. The following determinations are made: On or about 1/29/2024, C1 began yelling, slamming doors, and throwing objects at facility staff; C1's behavior escalated to threats of physical violence against staff; C1 exited the facility to wait for C1's bus and began throwing rocks at the house, car and Administrator; Administrator called Police and Regional Center Crisis staff for assistance and did lock the door to prevent C1 from entering the facility to carry out threats of violence against staff and or another client in care. Client witness states that C1 was not hit by the door closing and that C1 was aggressive and making threats to staff. Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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