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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803251
Report Date: 07/25/2025
Date Signed: 07/25/2025 02:22:26 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
04/10/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250410092323
FACILITY NAME:MASONIC GUEST HOME IIFACILITY NUMBER:
486803251
ADMINISTRATOR:LACAP, LEONIDAFACILITY TYPE:
740
ADDRESS:108 PINTO DRIVETELEPHONE:
(707) 644-3822
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leonida Lacap, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not seek timely medical care for resident in care

Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility Administrator Leonida Lacap.

Complaint alleges the facility did not seek timely medical care for resident (R1) in care and that the facility violated R1’s Personal Rights.

During the investigation, LPA reviewed R1’s file. LPA observed that R1 has attended multiple doctor’s visits. Additionally, LPA reviewed LIC 624s Unusual Incident/Injury reports filed with Community Care Licensing (CCL) for R1 for 2023, 2024 and 2025 which revealed that R1 was taken for medical treatment on multiple occasions as needed or recommended by medical professionals.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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-20250410092323
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: MASONIC GUEST HOME II
FACILITY NUMBER: 486803251
VISIT DATE: 07/25/2025
NARRATIVE
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...Continued from 9099

Information received during interview with R1, contradicted the allegation that they have been unable to get medical appointments when needed. The complaint further alleges that R1 is being over medicated. During record review of R1’s Centrally Stored Medication and Destruction Records LPA observed no indication or record of over administration of medication. The strength and quantity of the medications given to R1 were observed to match Doctors or psychiatrists’ orders. The complaint alleges that R1 is suddenly exhibiting a care need that was not previously known; however, during record review LPA observed that the care need was documented upon move-in on the Preadmission Appraisal.

The complaint alleges that R1’s routines have changed and that they are unable to leave the facility. Through record review and interviews, LPA observed that R1 injured themselves, preventing them from leaving the facility as much as they have done before the injury. Interview revealed that R1 has had medical interventions allowing them to be able to go out of the facility on their own.

Although the allegations 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 allegations are UNSUBSTANTIATED.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2