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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804235
Report Date: 09/15/2025
Date Signed: 09/15/2025 12:13:37 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
04/28/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250428160743
FACILITY NAME:HORIZON HOME-BAYSIDEFACILITY NUMBER:
486804235
ADMINISTRATOR:BURNETT, JOHNFACILITY TYPE:
735
ADDRESS:625 WHISPERING BAY LANETELEPHONE:
(415) 902-9634
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:4CENSUS: 2DATE:
09/15/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jadon seals-burnett, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced deliver findings regarding the above allegations and met with Jadon seals-burnett, House Manager. Administrator John Burnett was contacted via telephone and gave permission to House Manager to sign and receive report.

Reporting requirements – Complaint alleges that following an incident between a client and staff that resulted in injuries, the client’s responsible party was not notified. During this investigation CCL staff made observations, reviewed records, and conducted interviews. Statements made by client (C1) responsible party (RP) indicated that no contact was made and no incident report was sent to RP regarding an incident which resulted in bodily harm. Review of incident report submitted to CCL did not indicate that the incident report was sent to RP. Based upon observations, record review, and interviews, there is a preponderance of evidence to prove that the allegations have been SUBSTANTIATED and are valid.
Continued LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
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 5
Control Number 21-AS-20250428160743
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: HORIZON HOME-BAYSIDE
FACILITY NUMBER: 486804235
VISIT DATE: 09/15/2025
NARRATIVE
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Continued from LIC9099...

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D.

Exit interview conducted with House Manager, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250428160743
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: HORIZON HOME-BAYSIDE
FACILITY NUMBER: 486804235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
80061(f)
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80061(f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any. This requirement is not met as evidenced by:
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Licensee stated they would review section 80061 Reporting Requirements and submit a statement of their understanding to CCL by 5:00PM on Plan of Correction due date of 12/13/2025.
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Based on record review, interviews, and observations Licensee did not ensure that responsible party was informed of an incident that resulted in bodily harm which posed a potential health, safety, or personal rights risk to persons 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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/28/2025 and conducted by Evaluator Elias Magdaleno
COMPLAINT CONTROL NUMBER: 21-AS-20250428160743

FACILITY NAME:HORIZON HOME-BAYSIDEFACILITY NUMBER:
486804235
ADMINISTRATOR:BURNETT, JOHNFACILITY TYPE:
735
ADDRESS:625 WHISPERING BAY LANETELEPHONE:
(415) 902-9634
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:4CENSUS: 2DATE:
09/15/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jadon seals-burnett, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff physically abused client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Jadon seals-burnett, House Manager. Administrator John Burnett was contacted via telephone and gave permission to House Manager to sign and receive report.

Staff physically abused client in care – Complaint alleges that client was observed with a swollen, black eye, scratches and bruises from an altercation with staff (S1), who allegedly slammed the client (C1) again the wall and then picked them up and threw them outside. Client was then locked out while waiting for the police. During investigation CCL staff conducted interviews and reviewed records. Per investigation, C1 was admitted to the hospital where they presented a closed head injury consisting of an abrasion, contusion, and right toenail avulsion following an incident in the facility.
Continued LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250428160743
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: HORIZON HOME-BAYSIDE
FACILITY NUMBER: 486804235
VISIT DATE: 09/15/2025
NARRATIVE
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Continued from LIC9099A...

Interview with witness indicated they heard S1 screaming for help and described seeing S1 with C1 in a “bear hug” and then throw them outside. Witness denied seeing S1 punch C1. Per interview with S1, following a discussion between themselves and C1, C1 started poking them with a toy which S1 grabbed making C1 “irate.” Per S1, C1 then started attacking them. S1 denied hitting or punching C1 while getting C1 outside. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited. Exit interview conducted with House Manager, whose signature on form confirms receipt.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5