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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800621
Report Date: 08/05/2024
Date Signed: 08/05/2024 02:06:35 PM

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
07/29/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240729190749
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: 4DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Pia Baroni-AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Lack of staff supervision resulting in resident eloping the faciltiy.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alviso and Loera arrived unannounced to conduct a complaint investigation, on 8/5/24 at approximately 8:40am, and met with Administrator/Licensee Pia Baroni. Caregiver Justina Macias was working on shift upon LPAs arrival. One to one staff for client (C1) arrived during the LPAs inspection. Three clients (C1, C2, C3,) were home during the LPAs inspection.

It was alleged that "lack of staff supervision resulted in resident eloping the facility"; LPAs reviewed resident records and facility incident reports. LPA conducted interviews with staff, and other related parties. The investigation revealed that client C1 has AWOL the facility without staff's knowledge on three separate incidents; On the evening of 7/16/24, C1 left the facility around 7:30pm, off duty staff saw the client and notified the facility. Facility staff picked up the client in the community and returned them to the home. On 7/28/24 the client AWOL the facility, staff stated the client was supposed to be sleeping. C1 was picked up by CHP, wandering the Highway,and taken to the emergency room for assessment. Facility staff were notified and picked up C1 at the hospital/ER on 7/29 approximately sometime after 1:00pm.
Continued on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
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-20240729190749
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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621
VISIT DATE: 08/05/2024
NARRATIVE
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Per interviews with staff, S1 and S2, C1 AWOL without staff's knowledge on 8/2/24 around 8:30pm. The client was located by staff and was returned to the facility at approximately 11:00pm. The investigation has obtained information that supports that a violation has occurred.

Based on record reviews, and interviews conducted during this investigation, the allegation of "lack of staff supervision resulted in resident eloping the facility" is Substantiated. Deficiency will be cited, 80078 (a) Responsibility for Providing Care and Supervision- The licensee shall provide care and supervision as necessary to meet the client's needs., see LIC9099D.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency (s) on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Appeal Rights Given to the Administrator
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240729190749
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: WIMBLEDON HOUSE #1
FACILITY NUMBER: 496800621
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2024
Section Cited
CCR
80078(a)
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80078 (a) Responsibility for Providing Care and Supervision- The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: The investigation revealed that client C1 has AWOL the facility without staff's knowledge
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Licensee/Administrator to ensure the plan of care meets the client's needs, including ensuring sufficienting staffing. Ensure the staffing pla and care plan are meeting the clients (C1)current needs, at all times.
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on three separate incidents, 7/16, 7/29, and 8/2, 2024. See today's report,LIC9099. This is a health & safety, and personal rights risk to the client (s) in care.
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Submit staffing plan and updated care plan to meet clients current needs, POC due 8/5/2024.
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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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3