496800549-2-13-2024-21-AS-BMOS-D32PAM-20240304100858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800549
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:23:42 AM

Unfounded

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
11/13/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231113165043

FACILITY NAME:	ALVAREZ FAMILY HOME		FACILITY NUMBER:	496800549
ADMINISTRATOR:	MUTUNGA, EMMA		FACILITY TYPE:	740
ADDRESS:	2185 FLORAL WAY		TELEPHONE:	(707) 545-6464
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 4	DATE:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emma Mutunga-Administrator		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff caused injury to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso delivered findings of the Departments complaint investigation, on 2/13/24 at approximately 9:00am, and met with Administrator Emma Mutunga.
The reporting party (RP) alleges that staff (S1) caused injury to resident’s (R1) elbow. R1 was observed to have bruising and swelling to elbow. RP believes the injury may have occurred when staff assisted R1 in routine arm exercises. RP alleged C1s elbow may be fractured. The Department reviewed records and conducted interviews regarding the allegation of “staff caused injury to resident.” The investigation revealed R1 has range of motion limitations and a complex medical history. Interview conducted on 12/27/2023 with placement agency service coordinator provided no information revealing concern of R1s care residing at current placement. A medical professional was interviewed with knowledge of R1’s history and injury observed by RP. Interview on 1/3/2023 revealed the following information and diagnosis; R1 suffered a ruptured bicep tendon and not a fracture. Medical professional also informed, that the injury R1 sustained was not forceful and the rupture was spontaneous.
Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, “staff caused injury to resident” is UNFOUNDED. We have found that the complaint allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited.
Exit interview was conducted with the Administrator Emma Mutunga.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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