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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804098
Report Date: 08/08/2025
Date Signed: 08/08/2025 10:02:02 AM

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
06/18/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250618144146
FACILITY NAME:INFINITI CARE HOME #3FACILITY NUMBER:
486804098
ADMINISTRATOR:DEVERA, ALEHAFACILITY TYPE:
735
ADDRESS:353 ARLINGTON CIRCLETELEPHONE:
(707) 673-2078
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Aleha DeveraTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff did not respond to client during emergency
Staff did not have sufficient training to administer emergency medication
INVESTIGATION FINDINGS:
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On 08/08/2025 at approximately 9:25PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegations and was able to deliver findings. LPA met with Administrator Aleha Devera.
During the course of the investigation, the department made observations, conducted interviews, and gathered documents. There are allegations of " Staff did not respond to client during emergency and Staff did not have sufficient training to administer emergency medication.” The complaint alleged that on 06/17/2025, Resident 1 (R1) was bit by a spider and had an allergic reaction including hives and inability to swallow. R1 texted two caregivers on duty for medication and no one responded. Complaint also stated that R1 did not call or leave their room.
LPA conducted an interview with Staff 1 (S1), who stated that they did not receive any text message from R1 on June 17, 2025. LPA reviewed S1’s phone records and found no evidence of a text message received from R1.
Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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-20250618144146
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: INFINITI CARE HOME #3
FACILITY NUMBER: 486804098
VISIT DATE: 08/08/2025
NARRATIVE
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Continued From LIC9099...

S1 also provided a carrier-generated text log, which confirmed that no text messages were received from R1 between June 13, 2025 and June 18, 2025. Review of R1’s phone showed that a text message was sent to S1 on June 17, 2025 but did not show a delivery confirmation and may not have been successfully transmitted. S1 also reported that both staff were asleep at the time the message was sent, and no one attempted to wake them to report an emergency.
There is conflicting information regarding the allegation that staff failed to respond to an emergency. Both S1 and Staff 2 (S2) stated that they did not administer an EpiPen to R1. LPA could not verify whether an EpiPen was administered. Review of R1’s medication showed an unopened EpiPen prescribed to R1 in November 2024. During interview with R1, they stated that staff appeared unfamiliar with how to administer the EpiPen and used a YouTube video for guidance. Review of S1’s file showed that they have training on medication administration and has a nursing diploma. Based on interviews conducted record review, and observations made, these allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
No deficiencies cited.
Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
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