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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803543
Report Date: 12/09/2025
Date Signed: 12/09/2025 10:58:03 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
08/08/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250808084527
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLENFACILITY NUMBER:
486803543
ADMINISTRATOR:JOSE HERNANDEZFACILITY TYPE:
735
ADDRESS:630 WHISPERGLEN CTTELEPHONE:
(562) 447-0991
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:4CENSUS: 4DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Patti Amriz-Paiz, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are financially abusing residents
Staff do not ensure that resident's incontinence needs are met
Staff are operating the facility out of ratio
Staff do not distribute medications as prescribed
Staff do not follow resident's behavioral plan
Staff do not observe resident for change in condition
Personal Rights
INVESTIGATION FINDINGS:
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On 12/09/2025 at approximately 9:30 AM Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue the investigation and deliver findings regarding the above allegations and met with Program Administrator Patti Ambriz-Paiz.

The complaint alleges staff are financially abusing residents. The Reporting Party (RP) stated that the clients are to receive $170.00 P&I money each month however, the clients' financial records do not show balances or transactions.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20250808084527
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: INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLEN
FACILITY NUMBER: 486803543
VISIT DATE: 12/09/2025
NARRATIVE
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Continued from 9099....

LPA reviewed the totals in the P & I accounts at the facility and found they are less than $200 as clients have set up savings accounts where their monthly deposits go, and then an agreed upon amount (decided by client) is put in their P & I accounts to help clients budget and save their money. The savings accounts are kept separately and available for clients to review. The reporting party also stated that on 7/11/2025 staff gave client C1 a birthday party with their P&I money and staff did not get C1’s consent to use their money. LPA reviewed the complete accounts of clients in care and could find no evidence of staff mishandling client accounts. Facility provided copies of all receipts for expenses for C1’s party, which were covered by the facility, not C1. LPA also interviewed C1 who stated that their money was not used for any party expenses. Based on review of client accounts, interviews with clients and Administrator the LPA found no substantiating evidence that the staff are abusing clients financially. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Staff are financially abusing clients is UNSUBSTANTIATED.


The complaint alleges that Staff are operating the facility out of ratio. LPA observed that there are 4 clients and at the time of visit there appeared to be adequate staffing. During visits on 12/4/2025 and 12/09/2025 there were 2 clients at the facility and 2 at day programs and 6 staff present at the facility. Administrator was questioned about staffing levels and the requirements of the Individualized Program Plans (IPP Plans). Based on IPPs, client (C2) requires a 2 to 1 ratio as needed (during outings/heightened behaviors/requiring more care and supervision), not when the client is at the facility at baseline. LPA observed staff was at appropriate levels during visits on 8/12/2025, 12/04/2025 and 12/09/2025. LPA also reviewed staff schedules for the months of June 2025, July 2025, and, August 2025 and found staffing to be adequate. The facility was clean, clients’ rooms were clean and well-organized. C1 and C2, who were both at the facility and appeared to be well supervised. Based on IPP staffing requirements, staff schedules, interviews and LPA observations the allegation that Staff are operating the facility out of ratio is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is UNSUBSTANTIATED.

Continued on 9099-C2

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250808084527
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: INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLEN
FACILITY NUMBER: 486803543
VISIT DATE: 12/09/2025
NARRATIVE
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Continued from 9099-C

The complaint alleges Staff do not observe resident for change in condition and Staff do not ensure that resident's incontinence needs are met. The reporting party stated that staff do not monitor for change in condition and that the NOC shift staff do not change C2’s diapers, resulting in C2 laying in urine and feces and their diapers being ripped and shredded. LPA reviewed Behavior Plan and Care Plan for C2 and found that C2 is regularly taken to the bathroom every 2 hours, changed and attempted to toilet. Administrator stated that they are attempting to train C2 to use the bathroom. C2’s behaviors do not always make these toileting sessions easy. According to ADL care records for C2 for July and August 2025 C2 is taken to the bathroom at two hour intervals. C2 has behaviors around their incontinence and does remove their diaper and urinate and defecate on the floor of the restroom. There is no documentation in the client’s file stating that C2 shreds their diaper or urinates or defecates in the bed. Based on the care notes and care plan for C2 there is not a preponderance of evidence to substantiate that Staff do not ensure resident’s incontinence needs are met and Staff do not observe client for change in condition. The client is constantly under observation by at least one staff and regularly taken to the bathroom every two hours, according to documentation. Although the allegations may have happened there is not enough evidence to substantiate the allegations therefore the allegations that the Staff are not meeting the client’s incontinence needs and not observing the client for a change in condition is unsubstantiated.

The complaint alleges that Staff do not distribute medications as prescribed. The complainant stated that Staff (S1) instructed staff to give C2 a Tylenol to calm C2 down instead of giving C2 their prescribed PRN medication. LPA did a review of the Physician’s Report and the Medication Administration Record (MAR) for C2 for July and August, 2025 and found Tylenol was listed as a PRN, as is Risperdone. When LPA interviewed S1, they stated that C2 was given medications only as prescribed. The order for Tylenol states it is to be given for pain or fever. The Risperdone is ordered for bedtime, as needed. The Administrator stated that if client C2 is having behaviors or sleeplessness due to pain it is in the best interest of the client to address the cause (pain) before addressing the effect (behavior/sleeplessness), as stipulated in the physician’s orders, and, according to the Personal Rights, (3) A right to be free from corporal or unusual punishment…… or excessive medication. LPA’s review of the MAR and physician’s order found no evidence to substantiate the allegation. Although the allegation may have occurred there is not a preponderance of evidence to substantiate the allegation that Staff do not distribute medications as prescribed therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250808084527
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: INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLEN
FACILITY NUMBER: 486803543
VISIT DATE: 12/09/2025
NARRATIVE
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Continued from 9099-C2

The complaint alleges that Staff do not follow client’s behavior plan and Staff are violating resident’s personal rights. The reporting party (RP) stated that S1instructed staff to put C2 outside in the backyard to run and calm down when C2 has behaviors. S1 instructed staff to leave C2 outside in the backyard if C2 becomes aggressive with staff. RP stated that if C2 gets aggressive with staff, S1 instructed staff to leave C2 outside by himself and monitor him from inside of the facility. LPA reviewed C2’s behavior plan and found no restrictions for C2 to go to the backyard to run to calm down. LPA observed that the facility has provided C2 and the other clients with a swing and a trampoline for their use. The swing and trampoline are in a fenced yard. LPA observed several large windows for staff to observe clients in the backyard while allowing clients a sense of privacy yet still maintaining their safety. Based on LPA’s observations and review of behavior plan the allegations that the Staff do not follow client’s behavior plan and Staff are violating client’s personal rights are unsubstantiated. Although the allegations may have occurred there is not a preponderance of evidence therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4