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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804175
Report Date: 07/29/2025
Date Signed: 07/29/2025 01:33:19 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
01/22/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250122095345
FACILITY NAME:DIVINE MERCY FAMILY HOMEFACILITY NUMBER:
486804175
ADMINISTRATOR:BUI, MARIAFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria BuiTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Personal rights

INVESTIGATION FINDINGS:
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At approximately 11:50AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced and met with Maria Bui to deliver findings of a complaint investigation-initiated January 22, 2025. During the course of this investigation, outside records were reviewed, observations made, and interviews conducted.

Complaint alleges a personal rights violation due to a bruise and an open wound on the side of Resident (R1)’s) face. During the course of the investigation, the Department reviewed records, including hospital records, home health records and facility records. In addition, the Department conducted several interviews with Home Health staff, R1’s responsible party and facility staff. Based on information received during the investigation, the following was determined: R1 was seen by their PCP on 1/15/25 with no bruising/wound on their face. On 1/16/25, facility notified home health of a bruise on R1’s face. On 1/17/25, home health nurse observed bruise and wound on R1’s face. R1 had no recollection of a fall and denied pain. Facility denied that R1 had a fall. A review of R1’s hospital records state “Head skin lesion (the right cheek and right temple bruising) was likely due to R1 leaning their head onto railing. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
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-20250122095345
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: DIVINE MERCY FAMILY HOME
FACILITY NUMBER: 486804175
VISIT DATE: 07/29/2025
NARRATIVE
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 No signs of trauma.” Based on a review of the evidence, the face wound could not be attributed to a fall by R1. It is possible from R1 leaning on gurney railing during transport back to facility as PCP saw R1 on 01/15/2025 with no bruising or abrasions on the face and facility staff noted the area on R1’s return from their PCP appointment”.

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 personal rights is unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
01/22/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250122095345

FACILITY NAME:DIVINE MERCY FAMILY HOMEFACILITY NUMBER:
486804175
ADMINISTRATOR:BUI, MARIAFACILITY TYPE:
740
ADDRESS:105 MAYWOOD DRTELEPHONE:
(707) 334-1709
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria BuiTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Reporting requirements not met
INVESTIGATION FINDINGS:
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Complaint alleges reporting requirements not met. During the course of the investigation, the Department reviewed records, including hospital records, home health records and facility records. In addition, the Department conducted several interviews with Home Health staff, R1’s responsible party and facility staff. Based on information received during the investigation, the facility submitted a Special Incident Report on 1/27/2025 to the Department for a hospitalization on 1/17/2025, related to R1 being transported to a local hospital with bruising and wound to R1’s face. On 2/3/2025 a second Special incident report was received by the Department due to an emergency room visit on 1/26/2025. Facility met reporting requirements as required by Title 22 Regulations.

This agency has investigated the complaint alleging reporting requirements not met. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3