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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803924
Report Date: 06/02/2021
Date Signed: 06/02/2021 04:48:22 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20210210081334
FACILITY NAME:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:FLORES, MARIAFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 15DATE:
06/02/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria "Ines" FloresTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
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9
Resident is heavily medicated resulting in falls and inability to self feed.

Facility is not adequately staffed to meet residents' needs
INVESTIGATION FINDINGS:
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2
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5
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7
8
9
10
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13
At approximately 12:00PM, Licensing Program Analyst's (LPA's) Shannan Hansen and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA's met with Administrator Maria "Ines" Flores, toured the facility, interviewed staff and reviewed records. Based on interviews conducted and a review of resident files, LPA observed facility followed physician orders in the administration of medication. Based on records reviewed, facility reported each incident of a resident falling to the physician, CCL and responsible parties. Residents are observed for changes in condition and those changes are reported to the physician for guidance. LPA received copies of staffing schedules that showed staff were available to ensure the needs of the residents were met per regulation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No Citations issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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