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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496890049
Report Date: 11/18/2020
Date Signed: 11/18/2020 03:06:47 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
09/01/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200901155456
FACILITY NAME:EXCEPTIONAL CARE HOMEFACILITY NUMBER:
496890049
ADMINISTRATOR:JONES, RICHARDFACILITY TYPE:
740
ADDRESS:393 BONNIE AVENUETELEPHONE:
(707) 205-1228
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 4DATE:
11/18/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Orlando Madrid/Lead staffTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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9
Staff not properly disposing of medications.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst Leibert met with Caregiver Orlando Madrid, this date, for the purpose of delivering findings on the above complaint allegation. The visit was conducted via tele-vist due to the COVID - 19 precautions. Anonymous Complainant suspects that the Administrator has not properly disposed of residents' medications due to a report made to the Complainant by a relative that the Administrator's car was observed to contain empty pill bottles with names on them of people other than that of the Administrator. No other information provided. This department has attempted to get a statement from the Administrator on numerous occasions unsuccessfully. The attempts included letters; phone calls; and e-mails. Facility staff had no useful information regarding the allegation. This Department has not found evidence that would identify patient subjects of the empty pill bottles and/or whether this information, if known, would suggest improper disposing of medication. While the allegation may be true, based upon records reviewed and statements taken, there is not a preponderance of evidence to prove the allegation did, or did not, occur. Therefore, the allegation is 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: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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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