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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108231
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:04:16 AM

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
10/06/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231006160351
FACILITY NAME:MARK J HURLEY HOUSEFACILITY NUMBER:
490108231
ADMINISTRATOR:BRENEGAN, CATHERINEFACILITY TYPE:
735
ADDRESS:2641 NEOTOMASTELEPHONE:
(707) 575-9805
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 6DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:House Residential Supervisor, Michael SmithTIME COMPLETED:
10:19 AM
ALLEGATION(S):
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Facility is not in compliance with their fire clearance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of delivering complaint findings. LPA were greeted by House Residential Supervisor, Michael Smith and House Residential Supervisor, Lexus Fletcher.

During the course of the investigation, LPAs interviewed staff members, outside agency staff and conducted a tour of the facility during the opening of the complaint on October 9, 2023. Complaint alleges that Facility is not in compliance with their fire clearance. Based on interviews that were conducted with outside agency, LPAs confirmed that the structure in the backyard did need to be included in the Fire Clearance. Fire clearance on file dated 8/13/2020 and facility sketch did not include the structure in the backyard area used as a staff office. CCL requested an updated LIC850 based off the updated sketch provided by the facility. CCL received granted LIC850 from fire department including the structure used as a staff office. (See LIC 9099D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Assistant.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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-20231006160351
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: MARK J HURLEY HOUSE
FACILITY NUMBER: 490108231
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
80020(a)
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80020(a) Fire Clearance: (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by:
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Faciltiy provided an updated sketch including the office structure. CCL requested an updated LIC850 form fire department, which was received on 11/28/2023. Deficiency cleared at time of delivering findings.
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Based on interviews that were conducted with outside agencies, LPA confirmed that the structure in the backyard did need to have a Fire Clearance. Furthermore, LPA reviewed the STD 850 which confirmed the facility itself has an approved STD 850 from the Local Fire Jurisdiction, but the structure in the backyard was not Fire Cleared for a staff office which poses an immediate health, safety and personal rights risk to the clients 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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3