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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 03:07:17 PM

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
08/08/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240808112628
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:
03:22 PM
ALLEGATION(S):
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-Staff do not ensure client is allowed to receive phone calls.
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 do not ensure client is allowed to receive phone calls. The Reporting party stated every time that client (C1) receives a call, the facility staff either do not answer or never returns phone calls. Per Reporting Party, they recently called the facility and then got a call back on 07/31/2024 from the facility owner who said " C1 just had an episode and does not want to talk to anybody’, then they have been trying to call the facility since then and leaves a message, but owner calls them back and tell them other excuses why C1 can't call them back right now such as "they are not available, they don’t want to talk." Based on records review, C1 is conserved. The facility provided written messages with an outside party that had been attempting to reach C1 to talk to them since 8/1/2024 at 4:04pm and requesting a call back from the facility. Continues on LIC9099C...
Unsubstantiated
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 2
Control Number 21-AS-20240808112628
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...

On 8/3/2024 at 1:19pm outside party sent a message to the facility attempting to speak with facility staff or C1. On the same date, the facility staff have replied stating that they have reached out to C1’s service coordinator for guidance. During the investigation, LPA obtained pertinent records indicating that C1 is conserved. Also, the Department received written communication on 8/3/24 at 10:19pm requesting suggestions about how to properly address the situation indicating that C1’s preference to not receive calls from outside party and suggesting that their attempts to speak with C1 has caused a significant increase in C1’s physical aggression towards staff and other residents at the home leading to request an emergency meeting with C1’s responsible parties to obtain guidance. Incidents logs for this facility confirmed that the facility has submitted above incidents to CCL timely. Based on LPA’s confidential interviews conducted with pertinent parties, LPA received contradictory information regarding C1’s cell phone number accessibility from outside party to call them. However, there was a consensus between all parties that a previous incident not related to the facility could be affecting client’s preference of not receiving calls from outside party. A finding that the complaint allegation of staff does not ensure client is allowed to receive phone calls is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
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)
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