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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804149
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:09:22 PM

Substantiated


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
08/13/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240813101909
FACILITY NAME:SAKURA HOME 2FACILITY NUMBER:
486804149
ADMINISTRATOR:BALUYOT, JENNA NICHOLEFACILITY TYPE:
735
ADDRESS:2024 SWAN WAYTELEPHONE:
(916) 743-9292
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 2DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jenna Baluyot (Administrator)TIME COMPLETED:
03:24 PM
ALLEGATION(S):
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-Staff unlawfully evicted a client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Jenna Baluyot, Administrator.

The Department received an allegation of staff unlawful evicted a client. Per Reporting party, on 8/6/24 the facility sent client (C1) to the hospital for evaluation and treatment. However, C1 has been discharged, but the facility refuses to allow C1 to come back to the home, they have issued a 30-day eviction notice to C1 and they are refusing to assist C1 with placement. Based on records review, on 8/8/24 the Department received a lawful 30-day eviction notice issued to C1 addressed to C1’s responsible party due to a series of incidents involving C1 of disruptive behavior that represents a safety and well-being concern of other clients in care. LPA reviewed incident report logs for this facility, and it was confirmed that incident reports were submitted to CCL timely.

Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20240813101909
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: SAKURA HOME 2
FACILITY NUMBER: 486804149
VISIT DATE: 09/24/2024
NARRATIVE
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Continue from LIC9099...

Although, C1’s placement agency has reached out to LPA confirming that C1 is currently medical cleared, but they have concerns about C1 being discharged and returning to this facility due to recent diagnosis that it was unknown to them requiring higher level of care for C1 that the facility is not able to provide them and raised concerns about the health and safety of other clients in care at this facility. Per Service Coordinator, the facility staff have been actively involved collaborating and providing updates of C1’s behavior since their placement at this facility. Furthermore, the placement agency as of 8/14/24 have assessed C1’s eligibility requirements to stay at other facility that is able to meet their current needs until permanent residential option is found. Based on interviews conducted with C1’s responsible party all information above mentioned was confirmed without any concerns been raised. However, C1 was medically cleared on 8/9/24 at 9am, but the facility refused to take C1 back due to their behavior, and they were placed to another facility on 8/14/24. Per admission agreement C1 should be given 30-days eviction notice, but the facility refused to take C1 back until eviction could be effective until 9/8/2024. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240813101909
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: SAKURA HOME 2
FACILITY NUMBER: 486804149
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2024
Section Cited
CCR
85072(b)(12)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (12) To move from the facility in accordance with the terms of the Admission Agreement.
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The Administrator agrees to review the regulation and will submit a written policy on how the issue could be prevent in the future to ensure that clients admission agreements/personal rights are folllowed at all times for clients in care are by POC due date to clear the deficiency.
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Based on LPA's observations, interviews and records review, the licensee did not comply with this requirement by refusing C1 to come back to the facility after they were medically cleared on 8/9/24 and been at the hospital until 8/14/24 when they were relocated to another facility by their placement agency which poses a potential risk to the health and safety of client.
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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: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
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