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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108000
Report Date: 08/07/2026
Date Signed: 08/07/2026 10:02:35 AM

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
06/30/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260630093143
FACILITY NAME:MC HUGH CARE HOMEFACILITY NUMBER:
490108000
ADMINISTRATOR:DIZON, JASMINEFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:15CENSUS: 0DATE:
08/07/2026
ANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tiffany Dizon, LicenseeTIME COMPLETED:
10:10 PM
ALLEGATION(S):
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Facility did not follow mandatory reporting requirements
INVESTIGATION FINDINGS:
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At approximately 9:30 AM, Licensing Program Manager (LPM) Victoria Bertozzi and Licensing Program Analyst (LPA) Robert Frank arrived to deliver Complaint findings regarding the above allegation and met with Licensee Tiffany Dizon.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. On 6/29/2026 Community Care Licensing (CCL) received an SOC 341 Report of Suspected Dependent Adult/Elder Abuse. The SOC 341 was submitted by Witness W1. Witness W1 is not an employee of Mc Hugh Care Home. The SOC 341 stated that facility resident R1 was assaulted by resident R2. Resident R1 stated that they believe that they were assaulted by resident R2 because they were ignoring them. On 7/14/2026 facility staff member S1 stated that they were not aware of R2 assaulting R1 at the time but just recently heard about the incident.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
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 4
Control Number 21-AS-20260630093143
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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000
VISIT DATE: 08/07/2026
NARRATIVE
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...Continued from 9099

On 7/14/2026 facility staff member S2 stated that they were aware of the incident. S2, when asked if they knew about R2 assaulting R1 they stated, “Yes, R1 came up to me after the incident.” When S2 was asked if they called the police they stated, “no, R1 didn’t want anyone to be called. Per regulations, the facility should have filed a LIC 624 Unusual Incident/Injury Report. Additionally, the facility should have filed an SOC 341 Report of Suspected Dependent Adult/Elder Abuse document.

Based on LPA’s interviews and record review, 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
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20260630093143
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: MC HUGH CARE HOME
FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...including...(1) A written report shall be submitted...This report shall include...(D)Any incident which threatens the welfare, safety or health of any resident, ...
This requirement is not met as evidenced by:
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Facility is closing. Deficiency will be cleared during today's visit.
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Based on interview & record review, the licensee did not comply with the section cited above in that facility staff did not file a LIC 624 Unusual Incident/Injury Report with CCL which poses 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.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/30/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260630093143

FACILITY NAME:MC HUGH CARE HOMEFACILITY NUMBER:
490108000
ADMINISTRATOR:DIZON, JASMINEFACILITY TYPE:
740
ADDRESS:1000 GORDON LANETELEPHONE:
(707) 545-8213
CITY:SANTA ROSASTATE:CAZIP CODE:
95404
CAPACITY:15CENSUS: 0DATE:
08/07/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tiffany Dizon, LicenseeTIME COMPLETED:
10:10 PM
ALLEGATION(S):
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Lack of supervision resulting in client hitting another client
INVESTIGATION FINDINGS:
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Complaint alleges that lack of supervision resulted in a resident hitting another resident. On 6/29/2026 Community Care Licensing (CCL) received an SOC 341 Report of Suspected Dependent Adult/Elder Abuse. The SOC 341 was submitted by Witness W1. Witness W1 is not an employee of Mc Hugh Care Home. The SOC 341 stated that facility resident R1 was assaulted by resident R2. Resident R1 stated that they believe that they were assaulted by resident R2 because they were ignoring them. In an interview resident R1 stated that, “all of the sudden R2 hit me without a reason to hit me”. As the alleged assault was sudden the incident could not have been prevented by facility staff. So, 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, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. Copy of report, LIC-9099, LIC-9099-C, LIC-8099D, LIC-9099A, Plan of Corrections and Appeal Rights discussed and provided to Licensee Dizon. Signature on form confirms receipt of documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
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 4