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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800153
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:12:31 AM

Unsubstantiated


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
05/29/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20240529164649
FACILITY NAME:AMBER HOUSEFACILITY NUMBER:
496800153
ADMINISTRATOR:TERESITA ASTUDILLOFACILITY TYPE:
740
ADDRESS:6151 GABRIELLE DRIVETELEPHONE:
(707) 837-0222
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 6DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Andrew Cunha, Caregiver/Designated Responsible PartyTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Resident needs are not being met.
Facility is not ensuring resident’s safety.
Facility is not notifying responsible party of change in condition and/or needed medical care.
Facility failed to meet mandatory reporting requirements due to lack of staff training.
Personal rights.
INVESTIGATION FINDINGS:
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Andrew Cunha, Caregiver/Designated Responsible Party.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Resident needs are not being met, Facility is not ensuring resident’s safety, Facility is not notifying responsible party of change in condition and/or needed medical care, Facility failed to meet mandatory reporting requirements due to lack of staff training, and Personal rights.”

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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 3
Control Number 21-AS-20240529164649
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: AMBER HOUSE
FACILITY NUMBER: 496800153
VISIT DATE: 10/17/2024
NARRATIVE
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Continued from LIC9099...

“Resident needs are not being met” and “Facility is not ensuring resident’s safety” - Complainants alleged that Resident 1 (R1) needed a higher level of care due to increased agitation and that R1 was not safe at the facility because they weren’t being properly supervised. Complainants stated that R1 would go on walks by themselves and that the facility only had 1 staff member to care for 4 to 5 residents. Review of R1’s Physician’s Report dated 08/25/2023 states that R1 is able to leave the facility unassisted. During visits conducted on 06/06/2024 and 07/03/2024, LPA observed that there were 2 staff members on site. Interviews conducted with R1 and Resident 2 (R2) stated that they were happy at the facility and that they had no concerns about the care being provided at the facility. These allegations are Unsubstantiated.

“Facility is not notifying responsible party of change in condition and/or needed medical care” - Complainants alleged that the responsible party for R2 was not notified when they went to the hospital. Complainants also stated that R1 was prescribed a new medication and that the responsible party was not notified of the medication change. Review of R1’s file indicated that R2 is their responsible party. Interview conducted with R1 and R2 stated that R2 is the responsible party for R1. Review of R2’s file indicated that they are their own responsible party. Requests to the Complainant for additional documentation to verify the responsible parties were unsuccessful. Review of incident reports for R1 indicated that the facility would notify R2 appropriately. Interview conducted with R2 stated that they went to the hospital and was picked up by a family member. These allegations are Unsubstantiated.

“Facility failed to meet mandatory reporting requirements due to lack of staff training” - Complainants stated that facility staff told them that they haven’t received training for mandated reporting or for dementia behaviors such as wandering. Complainants also stated that facility staff did not report that R1 was hitting other residents. Review of staff files indicated that all staff have received training for mandated reporting and for dementia behaviors. Staff interviews conducted indicated that staff are aware of when they need to report incidents related to mandated reporting and for dementia behaviors. Staff interviews conducted provided conflicting statements. 3 of 4 interviews stated that while R1 has been observed to be verbally aggressive towards other residents, they have not seen R1 hit or be physically aggressive towards R2 or other residents in the facility, while 1 of 4 interviews conducted stated that they did not observe R1 hitting R2 or other residents but heard that it was happening. This allegation is Unsubstantiated.

Continued on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240529164649
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: AMBER HOUSE
FACILITY NUMBER: 496800153
VISIT DATE: 10/17/2024
NARRATIVE
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Continued from LIC9099C...

“Personal Rights” - Complainants alleged the following: R1 hit R2 on multiple occasions, Facility Licensee changed R1 and R2’s emergency contact/responsible party information to themselves, and Staff Member 1 (S1) impersonated a family member when R2 went to the hospital. Staff interviews conducted provided conflicting statements. 3 of 4 interviews stated that while R1 has been observed to be verbally aggressive towards other residents, they have not seen R1 hit or be physically aggressive towards R2 or other residents in the facility, while 1 of 4 interviews conducted stated that they did not observe R1 hitting R2 or other residents but heard that it was happening. Interview conducted with Licensee denied that R1 and R2’s emergency contact information was changed to be the Licensee and denied that S1 impersonated a family member. Interview conducted with S1 denied the allegation and stated that they introduced themselves to hospital staff as R2’s caregiver. Review of R1’s file indicated that R2 is their responsible party. Interview conducted with R1 and R2 stated that R2 is the responsible party for R1. Review of R2’s file indicated that they are their own responsible party. Requests to the complainant for additional documentation to verify responsible party information were unsuccessful. This allegation is Unsubstantiated.

A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and Confidential Names (LIC811) discussed and provided to Caregiver/Designated Responsible Party. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3