Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 233007628
Report Date: 03/17/2016
Date Signed: 03/17/2016 03:59:50 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
09/16/2015 and conducted by Evaluator Leticia Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20150916143900
FACILITY NAME:ALVAREZ, MARIA(ANGELICA) FCCHFACILITY NUMBER:
233007628
ADMINISTRATOR:ALVAREZ, MARIA (ANGELICA)FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 513-0520
CITY:UKIAHSTATE: ZIP CODE:
95482
CAPACITY:14CENSUS: 4DATE:
03/17/2016
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Maria (Angelica) AlvarezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unexplained injuries observed on child

Family member refused entry to into facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Leticia Rosales-Meza conducted an unannounced visit today to deliver the findings of the above allegations. This complaint was referred to the Department's Investigations Bureau and investigated by Kimberly Miller, Investigator. The investigation consisted of review of facility file, unannounced visit to the home, interviews with witnesses, and review of documents gathered during the course of the investigation. It was also alleged a family member refused entry into the facility. The Redwood Empire Regional Office investigated this allegation.

Based on available information these allegations are unable to be proved or disproven and therefore, the allegations are determined to be INCONCLUSIVE.

No citation is issued.

NOTICE OF SITE VISIT IS POSTED TO REMAIN POSTED FOR 30 DAYS
Inconclusive
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2016
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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