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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801219
Report Date: 10/14/2025
Date Signed: 10/14/2025 11:37:49 AM

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
09/11/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250911143745
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:
10/14/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josephine MendozaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
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2
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13
At approximately 09:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this faciity unannounced to conduct an investigation into the above allegation. LPA met with Licensee Josephine Mendoza, toured the building, interviewed staff and reviewed records. LPA received copies of documents.
Based on interviews conducted and records reviewed, LPA was not able to find evidence as to where or how the injury occurred. Resident, R1, was receiving Hospice services and a Hospice Aid was assisting R1 on 08/29/2025. Staff noticed R1's shirt sleeve was tight on 08/31/2025 and assisted R1 with changing the shirt. During this interaction, staff observed bruising and swelling on the arm. Based on interviews conducted, there were no prior signs of injury or pain. Staff notified the Licensee upon discovery. Hospice was contacted early, on 09/01/2025, and the duty nurse was spoken to. Hospice personnel arrived at approximately 3:45PM and assessed R1 on 09/01/2025 and ordered a mobile xray. The xray occurred on 09/09/2025, discovering a fracture. Licensee notified CCLD on 09/10/2025 of the incident. R1 did sustain an unexplained injury while in care, however, there is no indication how it occurred.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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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