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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803924
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:44:18 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
09/08/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220908090203
FACILITY NAME:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 21DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Alexander VarshavskyTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility is not being kept at a comfortable temperature
INVESTIGATION FINDINGS:
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Licensing Program Analyst Erik Gonzalez Campos arrived unannounced on 09/08/2022 at approximately 1:30 PM to conduct an initial complaint inspection regarding the allegation that facility is not being kept at a comfortable temperature. LPA met with Licensee/Administrator, Alexander Varshavsky.

LPA toured the facility and made observations. The majority of residents were observed congregated in the main common area upon LPA arrival. Facility has placed fans throughout the facility and facility staff were observed providing residents with water, popsicles and cooling towels. Fans were observed in all resident bedrooms inspected. LPA observed facility thermostat reading 87 Degrees Fahrenheit in common area despite attempts to cool the area with fans. The recorded exterior temperature was 105 degrees at the time of the inspection. Regulation requires facilities to cool interior temperature to between 78 and 85 degrees F or in cases of extreme heat to 30 degrees less than the outside temperature. Facility does not currently have a centralized air conditioning unit.

Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
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-20220908090203
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: SONOMAMODELX
FACILITY NUMBER: 496803924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited
CCR
87303(b)(2)
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87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observations
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Facility will ensure a plan is put in place to reduce the temperature in the facility per regulation for extreme heat. LPA discussed
various options within the community including possible cooling stations. Plan to be submitted to Community Care Licensing by 09/09/2022.
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this requirement was not met as evidenced by: LPA observed an interior temperature reading of 87 degrees F while exterior temperature was 105 degrees F during inspection on 09/08/2022 which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220908090203
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: SONOMAMODELX
FACILITY NUMBER: 496803924
VISIT DATE: 09/08/2022
NARRATIVE
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The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.

Exit interview conducted with administrator/licensee and a copy of the report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3