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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803924
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:17:49 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
10/13/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211013124957
FACILITY NAME:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:FLORES, MARIAFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 21DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria FloresTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not consistently screening visitors for COVID-19 symptoms prior to entering the facility.
Residents are not wearing masks in communal settings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Maria Flores and discussed the findings. During the course of this investigation site visits to the facility were made and observations taken; Records and documents were obtained and reviewed; statements were taken from staff, residents, and witnesses. The following determinations are made: While not required by regulation, the facility's mitigation plan calls for residents to wear masks in communal settings if tolerated; residents have been observed without masks in communal settings; most residents have a diagnosis of cognitive decline and cannot be relied upon to give factual statements; staff indicate that most residents do not tolerate masks and often complain or remove them from the face; With the exception of the Complainant, eight out of eight witnesses interviewed stated that the Covid protocols are followed by the staff when witnesses have visited the facility. While the allegations may be true, based upon the records reviewed and statements taken, the preponderance of evidence standard has not been met. Therefore, the allegations are UNSUBSTANTIATED.
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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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