496801929-3-2-2022-21-AS-KMOA-CCMLUH-20220318090356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801929
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:17:51 PM

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
01/18/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220118113240

FACILITY NAME:	FRIENDS HOUSE		FACILITY NUMBER:	496801929
ADMINISTRATOR:	CARENBAUER, JACLYN		FACILITY TYPE:	741
ADDRESS:	684 BENICIA DRIVE		TELEPHONE:	(707) 538-0152
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	145	CENSUS: 78	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator, Jaclyn Carenbauer		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not following proper protocol for COVID-19
No one wears masks at the facility
Staff member yells at residents

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 3/2/2022 for the purpose of delivering findings. LPA met with Jaclyn Carenbauer, administrator.

There are allegations of facility is not following proper protocol for COVID-19 and no one wears masks at the facility. LPA made two visits to the facility. On both occasions LPA was screened by staff before being permitted to enter facility. During first inspection LPA toured facility and observed all staff and residents wearing masks. During the second inspection, LPA observed all staff and some residents wearing masks. LPA observed COVID postings and hand sanitizer throughout the facility. LPA observed PPE cart with necessary PPE to support a resident in isolation. LPA interviewed one staff who indicated that during COVID outbreak staff were required to wear N95s, gowns, gloves, and googles.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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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Control Number 21-AS-20220118113240

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: FRIENDS HOUSE	FACILITY NUMBER: 496801929
	VISIT DATE: 03/02/2022

NARRATIVE

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LPA interviewed two residents who indicated that during COVID outbreak they remained primarily in their bedroom. Staff and administrator indicated that there is one resident who tested positive who has wandering behavior and will not tolerate wearing masks. Although the allegations may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

There is an allegation of staff yelling at residents. LPA interviewed two residents. Both residents denied mistreatment or being yelled at. LPA interviewed staff who indicated that residents are receptive to care and will vocalize their needs. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with administrator and a copy of this report given to the facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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