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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210108102
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:15:51 AM

Unfounded


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
01/30/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20230130091342
FACILITY NAME:VILLA MARIN AMBULATORY CARE UNITFACILITY NUMBER:
210108102
ADMINISTRATOR:DURANCZYK, PAULFACILITY TYPE:
741
ADDRESS:100 THORNDALE DRIVETELEPHONE:
(415) 499-8711
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:28CENSUS: 9DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Paul DuranczykTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with the front desk receptionists. Administrator, Paul Duranczyk arrived later during visit at approximately 9:45AM.

During the course of the investigation, LPA Felias reviewed and requested documents, conducted interviews, and made observations.There is an allegation that the Facility is in disrepair. During visit conducted on 2/9/2023, the allegation listed in the complaint was observed to be located in the Independent Living (IL) portion of the facility. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations for that portion of the facility. LPA was unable to identify any deficiencies in the maintenance of the property on the Assisted Living (AL) side of the facility where CCL does have jurisdiction.

Continued on LIC9099C

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 2
Control Number 21-AS-20230130091342
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: VILLA MARIN AMBULATORY CARE UNIT
FACILITY NUMBER: 210108102
VISIT DATE: 02/09/2023
NARRATIVE
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Continued from LIC9099

Based on record review, interviews conducted, and observations made, the allegation that Facility is in disrepair is Unfounded. A finding that the Complaint is Unfounded means that the allegation was false, could not have happened and/or is without a reasonable basis.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2