496804055-8-3-2023-21-AS-HDBI-CUKP34-20230810105656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804055
Report Date: 07/18/2023
Date Signed: 08/03/2023 10:24:36 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
06/01/2023 and conducted by Evaluator Shannan Hansen

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230601144419

FACILITY NAME:	ALTA CARE HOME		FACILITY NUMBER:	496804055
ADMINISTRATOR:	MONTE, AIRA MELANIE V.		FACILITY TYPE:	740
ADDRESS:	96 ALTA DRIVE		TELEPHONE:	(707) 508-7634
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Laarni Lockerbie, Licensee & Aira Melanie V. Monte, Administrator		TIME COMPLETED:	08:45 AM

ALLEGATION(S):

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Staff handled resident in a rough manner
Staff withheld water from resident

INVESTIGATION FINDINGS:

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*** Amended Licensing Program Analysts (LPA) Hansen arrived unannounced at the facility to deliver findings regarding the above allegations. LPA met with Aira Melanie V. Monte, Administrator & Laarni Lockerbie, Licensee.
Staff handled resident in a rough manner & Staff withheld water from resident– Complaint alleges resident got up out of bed after staff directed not to get out of bed and staff allegedly grabbed resident by the back of the neck and forced back into bed. LPA obtained police report, conducted interviews with residents, staff, and other individuals. Reporting party and resident were unable to identify alleged staff. Resident moved from facility within a weeks’ time period, LPA conducted collateral visit to conduct interviews regarding visible bruising. Based on LPA’s interview with reporting party and collateral visit, no bruising was viewed or reported. It was also alleged staff withheld water from residents – LPA made observations on 6/6/2023 and observed residents with water in glasses in their rooms. LPA conducted interviews with 2 residents who confirmed water is offered when desired. LPA is unable to prove water is being withheld from residents. See LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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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Control Number 21-AS-20230601144419

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: ALTA CARE HOME	FACILITY NUMBER: 496804055
	VISIT DATE: 07/18/2023

NARRATIVE

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Based on LPAs observations, record reviews, interviews with staff, residents and conflicting information obtained from parties, there is insufficient information to prove or disprove the allegations listed above. 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 allegation is Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

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