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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804059
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:50:33 PM

Substantiated


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
09/04/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20240904015421
FACILITY NAME:ARVEAH'S CARE HOMES 3FACILITY NUMBER:
486804059
ADMINISTRATOR:MARTINEZ-DAVIS, LEAHFACILITY TYPE:
740
ADDRESS:2033 MARSHALL ROADTELEPHONE:
(530) 662-6055
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 3DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:John Piolo Danting, Designated Responsible PartyTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not report an incident to the licensing agency.
INVESTIGATION FINDINGS:
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On 12/06/2024, at approximately 11:55 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings for the above allegation and met with John Piolo Danting, Designated Responsible Party. Reporting Party (RP) alleges that Licensees failed to report to Community Care Licensing (CCL) a reported potential incident of physical assault by former Staff 1 (S1) on Resident 1 (R1).

LPA conducted 10-day on 09/06/2024 and conducted interviews, made observations, and obtained documents. LPA interviewed 5 of 6 residents, Licensees, Staff 2 (S2), Staff 3 (S3), and Staff 4 (S4). Said interviews confirmed that Licensees were informed of the potential physical assault and Licensees failed to report the allegation to CCL. Licensees were unable to provide proof that an incident report was submitted to CCL and LPA confirmed that CCL did not receive an report for the alleged incident.

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

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 3
Control Number 21-AS-20240904015421
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: ARVEAH'S CARE HOMES 3
FACILITY NUMBER: 486804059
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC9099...

Based on interviews conducted, observations made, and record review, the allegation listed above is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240904015421
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: ARVEAH'S CARE HOMES 3
FACILITY NUMBER: 486804059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2024
Section Cited
CCR
87211(c)
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87211(c) Reporting Requirements:
Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement...
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Licensee to submit self-certification that they will ensure all known actual and potential incidents are reported to CCL within the required timeframes and that the regulation has been reviewed with care staff. LIcensee agrees to submit this to CCL by POC due date 12/9/2024.
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agency within twenty-four (24) hours....
This requirement was not met as evidenced by:
Licensee failed to report a known potential incident of abuse to CCL which posed a health, safety, and personal rights violation to residents in care.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3