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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801091
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:09:50 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
04/11/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220411082204
FACILITY NAME:HANNA HOUSE SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR:ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 5DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adalberto Ojeda-MendezTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Serious neglect resulting in injury
Staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Leibert arrived unannounced and delivered findings to the Administrator. Interviews with residents and facility staff were conducted. Medical records for R1were reviewed and surveillance video was examined. R1 is reported to have fallen at the facility. Surveillance footage in common areas has corroborated the fall, along with staff interviews. Surveillance footage revealed staff responded to R1’s fall within 14 seconds. After assessing R1, staff noticed a change in her condition. In response, R1 was transported to the hospital. Based on the estimated time of the fall and departure to the hospital, R1 was at the facility for approximately 88 minutes
(one hour and 28 minutes). In this time, R1 was immediately assessed and directly observed for
changes in her condition. Upon her complaint of increased pain, staff communicated with R1’s
family to advise she would be transported to the hospital. R1 is not a fall risk and does not require increased supervision. The allegations “Serious neglect resulting in injury” and “Staff did not seek medical attention in a timely manner” are UNFOUNDED, meaning allegations are false and/or without a reasonable basis. The allegations are DISMISSED. No citations issued. Report left at facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
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 2
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
04/11/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220411082204

FACILITY NAME:HANNA HOUSE SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR:ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 5DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adalberto Ojeda-MendezTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Leibert arrives unannounced for the purpose of delivering findings on this complaint allegation. LPA met with the Administrator and discussed findings. Complainant alleges that S1 spoke in a disrespectful way to R1 while accompanying R1 at the Emergency room of a hospital. S1 denies the allegation and states that it is necessary to be directive with R1 in order to elicit compliant behavior and that R1’s personal rights are always respected. A review of medical records and narratives for the date in question and statements taken from witnesses produced no evidence to show a violation of R1’s rights. Although the allegation may be true, or valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

No citations issued. Copy of report left at facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2