496801929-4-28-2023-21-AS-CMAZ-CRGVEL-20230503162232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801929
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:47:53 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
04/10/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230410094256

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: 82	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Prospective Administrator, Robert Rubio		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not possess a current first aide certificate

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Friends House for the purpose of delivering complaint findings. LPA was greeted at the door by Prospective Administrator, Robert Rubio, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed facility records, interviewed staff a resident and various outside parties.

Complaint alleges that Staff do not possess a current first aide certificate. Based on an observation of the facility records conducted on April 12, 2023, LPA learned that 2 out of 5 staff members does not have a valid First Aid/CPR card on file. Furthermore, LPA educated the Administrator on April 12, 2023 on the importance of having valid First Aid/CPR for staff members that care for residents. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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 5

Control Number 21-AS-20230410094256

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: 04/28/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given along with this report.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20230410094256

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/01/2023 Section Cited CCR 87411(c)(1)	1 2 3 4 5 6 7	87411(c)(1) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Plan of Correction two staff need to obtain First Aid training as required by regulation; Submit copies of first aid training certificates by due date May 1, 2023. Furthermore, Licensee shall submit a plan for future compliance with this regulation.
	8 9 10 11 12 13 14	Based on record review conducted on April 12, 2023, the licensee did not comply with the section cited above in 2 out of 5 staff members did not have a current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14	Plan of Correction due on May 1, 2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/10/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230410094256

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: 82	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Prospective Administrator, Robert Rubio		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly trained

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Friends House for the purpose of delivering complaint findings. LPA was greeted at the door by Prospective Administrator, Robert Rubio, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed resident(s) records, facility records, interviewed staff, a resident and various outside parties.

Complaint alleges that Staff are not properly trained. Based on an observation of the facility records conducted on April 20, 2023, LPA learned that the staff member in question had sufficient hours of training. During interviewing, it was disclosed to the LPA that the staff member was handed the medication cart key but did not dispensed medication to the residents in care during the timeframe in question. Furthermore, it was disclosed during a follow-up interview with a witness that medications were distributed accordingly and in a timely manner. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20230410094256

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: 04/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A finding that the complaint allegation of Staff are not properly trained is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Assistant Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5