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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803606
Report Date: 06/09/2026
Date Signed: 06/09/2026 11:09:15 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
06/01/2026 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20260601221435
FACILITY NAME:LONG LIFE LIVING INC IIFACILITY NUMBER:
216803606
ADMINISTRATOR:CHANG, FAYEFACILITY TYPE:
740
ADDRESS:15 PIKES PEAK DRIVETELEPHONE:
(415) 472-5876
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
06/09/2026
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator, Justine HerreraTIME COMPLETED:
09:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of staff supervision resulting in resident sustaining a fracture while in care
Staff did not address resident's fall risk
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 8:55AM, Licensing Program Analyst arrived unannounced at the facility met with Administrator, Justine Herrera. The purpose of the visit was to close a complaint investigation regarding the above allegations. Complaint investigation was opened in error under the wrong facility number, as the resident indicated in the complaint report does not reside at this facility address.

Based on record review and observations made, these allegations are Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026
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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