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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804080
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:23:54 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
08/11/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230811114158
FACILITY NAME:DANLE'S CARE HOME IIIFACILITY NUMBER:
486804080
ADMINISTRATOR:DANLE, SINNINFACILITY TYPE:
735
ADDRESS:811 WHITE WING LANETELEPHONE:
(707) 759-2028
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:4CENSUS: 4DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Sinnin Danle, LicenseeTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Staff mismanaged resident's medications
INVESTIGATION FINDINGS:
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On 11/30/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Licensee, Sinnin Danle. The Department gathered client (C1) medical records. LPA’s Tobola & Cuadra toured the facility, interviewed staff and reviewed client records during the course of the investigation.
Complaint alleges staff mismanaged resident's medications resulting in client (C1) hospitalization on 8/8/2023 due to an asthma attack. Based on interviews with LPA Cuadra & facility staff (S1 & S2), LPA received inconsistent statements on client C1 being assisted with their prescription inhaler. Based on a review of C1’s medical records and vitals measurements, although C1 was admitted to the hospital on 8/8/2023 with an 83% oxygen saturation, there is no indication that C1 was hospitalized due to a missed medication. Due to inconsistent statements and a lack of corroborating evidence, the allegation is found to be unsubstantiated.

Continud onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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-20230811114158
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: DANLE'S CARE HOME III
FACILITY NUMBER: 486804080
VISIT DATE: 11/30/2023
NARRATIVE
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Allegation, staff mismanaged resident's medications UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights Given.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2