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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800621
Report Date: 11/28/2022
Date Signed: 11/28/2022 02:07:00 PM

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
10/19/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221019125728
FACILITY NAME:WIMBLEDON HOUSE #1FACILITY NUMBER:
496800621
ADMINISTRATOR:BARONI, PIA E.FACILITY TYPE:
735
ADDRESS:629 WEST 3RD STREETTELEPHONE:
(707) 527-7628
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:5CENSUS: 2DATE:
11/28/2022
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Elizabeth Ramirez (Staff)TIME COMPLETED:
02:22 PM
ALLEGATION(S):
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Facility failed to ensure the building was clean, safe, sanitary and in good repair at all times
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with designated staff Elizabeth Ramirez.

It was alleged that facility failed to ensure the building was clean, safe, sanitary and in good repair at all times. Per outside Party, bedrooms light fixture and switch was observed removed from ceiling with wiring exposed and exposed wiring on wall light switches. Screen door leading to outside was observed in bad condition needing repair and facility appeared to be very messy, clothes, belongs on client’s floor. Outside party expressed concern of the facility oversight due to observed condition of the facility. During LPA’s visit conducted on 10/25/2022, it was revealed that Licensee has been out of town since October 1, 2022 until December 1, 2022 and designated staff (S1) at time of visit did not have any relief staff identified. During the tour of the physical plant, staff confirmed items that needed repair and ensured that they were already fixed. However, based on supporting evidence and photos obtained on 11/17/22 the facility has not ensured that all the rooms are kept clean, safe, sanitary and in good repair at all times.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
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-20221019125728
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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621
VISIT DATE: 11/28/2022
NARRATIVE
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Continued from LIC9099...

LPA/staff toured the facility including resident’s bedrooms and observed them not clean and organized which poses a tripping hazard for residents in care. During today's visit, LPA/staff toured the facility including Licensee's living room area and no obstructions were observed at the time of visit. Staff/LPA observed facility for the most part clean and it was confirmed by staff that during last visit they provided the wrong information referring to the bedroom with wiring issue because the bedroom with the exposed wiring issue is the licensee's bedroom that is being remodeled and clients don't have access. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Appeal Rights Given. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. 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: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221019125728
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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2022
Section Cited
CCR
80087(a)
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Buildings and Grounds 80087(a) - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees, and visitors. **This requirement was not met as evidence by:
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Licensee agreed to provide photos of proof of correction including repairing hazard wiring issue and submit written plan of action addressing areas of concern to CCL by POC due date. Regional office will be conducting an Informal Meeting with Licensee time and date to be determined.
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Based on observations and interviews conducted with staff, the facility did not ensure to keep resident’s rooms clean, safe, sanitary and in good repair at all times which poses an immediate risk to the health and safety to 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: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3