<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801219
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:10:34 PM

Substantiated


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
06/24/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250624132401
FACILITY NAME:MENDOZA CARE HOME IIIFACILITY NUMBER:
486801219
ADMINISTRATOR:JOSEPHINE MENDOZAFACILITY TYPE:
740
ADDRESS:241 LEXINGTON DR.TELEPHONE:
(707) 553-2580
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maria Rivera, House ManagerTIME COMPLETED:
01:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Loera arrived unannounced and met with Maria Rivera, House Manager to deliver findings of a complaint investigation-initiated June 27, 2025. During the course of this investigation, outside records were reviewed, observations made, police report and body worn camera reviewed, interviews conducted.

Complaint alleges a personal rights violation due to staff (S1) slapping Resident (R1). Based on interviews that were conducted with facility staff, outside parties and records reviewed, it was determined that during the investigation S1 admits to hitting R1 on the forehead to get them to sit in the chair. Licensee stated that R1 was not slapped and that it was a misunderstanding. S1 used their hand to push R1 on the forehead to sit back into their chair to avoid R1 from wandering away from the facility and the slap was the chair hitting the wall. S1 stated that they used their hand to push R1 on the forehead to sit back into their chair and lost their balance falling forward and hitting the wall with their hands causing the slapping sound. Although there are inconsistencies regarding R1 being slapped, there is sufficient evidence that R1’s personal rights were violated by being pushed on the forehead to sit in their chair.

continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 3
Control Number 21-AS-20250624132401
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: MENDOZA CARE HOME III
FACILITY NUMBER: 486801219
VISIT DATE: 07/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, and/or Health and Safety Code is being cited on the attached LIC 9099D. Appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20250624132401
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: MENDOZA CARE HOME III
FACILITY NUMBER: 486801219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2025
Section Cited
HSC
1569.269(a)(10)
1
2
3
4
5
6
7
1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse......
1
2
3
4
5
6
7
Licensee to schedule training with all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 7/30/2025. Proof of training to include type of training along with staff names and signatures. Training to be submitted by POC due date of 08/11/2025.
8
9
10
11
12
13
14
This requirement was not met as evidence by: R1 being pushed down on the forehead to remain seated by S1. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3