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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804246
Report Date: 03/18/2026
Date Signed: 03/18/2026 12:30:11 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
01/05/2026 and conducted by Evaluator Ethel Contreras
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20260105082241
FACILITY NAME:4 SEASONSFACILITY NUMBER:
486804246
ADMINISTRATOR:MATHURIN, HERBYFACILITY TYPE:
735
ADDRESS:907 HARLEQUIN WAYTELEPHONE:
(415) 629-1205
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:5CENSUS: 4DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Herby Mathurin-Administrator TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility staff are not ensuring dietary needs of client(s) are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ethel Contreras met with Administrator Herby Mathurin at the Santa Rosa Regional Office for an Informal Meeting and to deliver findings for the above allegations. During the course of the investigation, LPA interviewed staff, made observations, and reviewed records. Complaint alleges facility staff are not ensuring dietary needs of client(s) are met.

During investigation, LPA observed food present in the kitchen refrigerator (photos taken), however, LPA did not observe enough food for four clients to meet the minimum requirement of 2 days of perishable and 7 days of non-perishable food. LPA observed second refrigerator located in garage containing approximately 6 gallons of juice present, however LPA did not observe a sufficient amount of milk or milk products. LPA observed in freezer several boxes of frozen dinners, no other food present in freezer. In addition, staff showed location of snacks. LPA observed one box of popcorn and no other additional snacks observed to meet the minimum requirement of 7 days. Administrator (S1) stated during interview that clients are eating all the food the same day that it is bought. S1 also stated that if clients ask for certain foods, they will purchase food that same day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Ethel Contreras
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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-20260105082241
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: 4 SEASONS
FACILITY NUMBER: 486804246
VISIT DATE: 03/18/2026
NARRATIVE
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continued from 9099....

LPA advised S1 that a 2-day supply of perishable and 7-day supply of non-perishable foods needs to be in the facility at all times. Based on LPA’s interviews and observations, 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, are being cited on the attached 9099D.

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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Ethel Contreras
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260105082241
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: 4 SEASONS
FACILITY NUMBER: 486804246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2026
Section Cited
CCR
85076(d)(1)
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85076(d)(1)Food Services:Licensee shall meet the following food supply and storage requirements:(1) Supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premise. This requirement has not been met as required by:
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Facility to submit plan on how they will ensure food is maintained on premises per regulation by Plan of Correction due date 3/27/2026.
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Based on LPA observation,the licensee did not comply with the section cited above in that facility did not have required quantity of food or food that meets the required food supply, which poses an 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: Kimberley Mota
LICENSING EVALUATOR NAME: Ethel Contreras
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5