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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803941
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:43:17 AM

Unsubstantiated


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
05/18/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220518112517
FACILITY NAME:ASHKALON HOUSEFACILITY NUMBER:
496803941
ADMINISTRATOR:DADA, VICTOR C.FACILITY TYPE:
740
ADDRESS:912 DETURK AVE.TELEPHONE:
(707) 478-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 4DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee, Victor DadaTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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9
Staff failed to meet resident's incontinence care needs
INVESTIGATION FINDINGS:
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2
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5
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13
Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Licensee, Victor Dada.

During investigation LPA conducted interviews, reviewed documents and made observations.

Staff failed to meet resident's incontinence care needs - Complaint alleges that a resident in the facility has been observed multiple times in urine and feces. Interview revealed one incident of resident being observed as having a bowel movement in their adult brief but it was not clear how long it had been since the resident had incontinence care. Evidence did not support the allegation that this has happened multiple times or that there was a delay in resident receving incontinence care.

A finding that the complaint allegation that staff failed to meet resident's incontinence care needs was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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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