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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801218
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:10:57 PM

Unsubstantiated


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
03/21/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250321094711
FACILITY NAME:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR:CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lourdes Gadia, Designated Responsible PartyTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not ensure that resident is wearing clean clothing
INVESTIGATION FINDINGS:
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On 06/19/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250321094711 investigation findings regarding the above allegation and met with Lourdes Gadia, Designated Responsible Party (DRP). Reporting Party (RP) alleges that the facility staff do not ensure that Resident 1 (R1) is wearing clean clothing.

LPA Florio conducted 10-day complaint investigation visit on 03/27/2025 and obtained documents, made observations, and conducted interviews. During this visit, R1 was observed wearing clean clothing and no signs of soiled garmets. Additionally, during this visit, it was revealed through interviews with staff and House Manager (HM) and progress notes dated 03/15/2025-03/20/2025 that R1 refused personal care on more than one occasion, somtimes choosing to remain in the same clothes from the previous day. Based on observations made, interviews conducted, and records reviewed, the department received conflicting information.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 2
Control Number 21-AS-20250321094711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DOVER VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801218
VISIT DATE: 06/19/2025
NARRATIVE
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Continued from LIC9099...

Based on interviews conducted and records obtained, the allegation that the facility staff do not ensure that (R1) is wearing clean clothing is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
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