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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486830786
Report Date: 04/10/2023
Date Signed: 04/10/2023 01:08:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/20/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230320083448
FACILITY NAME:OUR LADY OF PEACE HOME CAREFACILITY NUMBER:
486830786
ADMINISTRATOR:CABE, ROMEOFACILITY TYPE:
740
ADDRESS:900 DAWNVIEW WAYTELEPHONE:
(707) 447-1920
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 5DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Romeo CabeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff does not provide a diaper to resident.
Staff does not provide clothing to resident.
Staff does not ensure resident's hygiene needs are met.
Staff does not provide nutritious meals.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Our Lady of Peace Home Care for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Romeo Cabe, and was granted access into the facility.

During the course of the investigation, LPA reviewed resident records, facility records, interviewed staff, residents in care, a witness and an outside provider.

Complaint alleges that staff do not provide a diaper to resident. Based of interviews that were conducted, LPA received inconsistent statements regarding this allegation. LPA conducted a tour of the facility during the opening of the complaint on March 23, 2023 and found that the facility was clean and at a comfortable temperature. Furthermore, LPA observed incontinence materials safely stored in resident rooms and accessible to staff members whenever needed.

(Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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 4
Control Number 21-AS-20230320083448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR LADY OF PEACE HOME CARE
FACILITY NUMBER: 486830786
VISIT DATE: 04/10/2023
NARRATIVE
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Complaint alleges that staff do not provide clothing to resident. Based off of interviews and observations on March 23, 2023, LPA observed residents to be properly clothed. Furthermore, LPA observed residents to be content in placement. LPA could not prove or disprove the allegation due to inconsistent statements made during the course of the investigation.

Complaint alleges that staff do not ensure resident’s hygiene needs are met. Based off of interviews and observations on March 23, 2023, LPA observed residents to be content in placement. Interviews with residents, witness and an outside provider yielded no concerns with facility operations which includes the care of the residents in placement. LPA could not prove or disprove the allegation due to inconsistent statements made during the course of the investigation. Furthermore, LPA conducted a tour of the facility during the opening of the complaint on March 23, 2023 and found that the facility was clean and at a comfortable temperature. LPA also toured resident rooms which smelt appropriate during the opening of the complaint on March 23, 2023.

Complaint alleges that staff does not provide nutritious meals. Based off of interviews that were conducted and document reviews that were conducted, LPA could not prove or disprove that staff do not provide residents with nutritious meals. On March 24, 2023, LPA reviewed the Facility Food menu and found that menu to be appropriately filled out with times that meals are served.

A finding that the complaint allegations of staff do not provide a diaper to resident, staff do not provide clothing to resident, staff do not ensure resident’s hygiene needs are met and staff does not provide nutritious meals are unsubstantiated meaning that 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 allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/20/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230320083448

FACILITY NAME:OUR LADY OF PEACE HOME CAREFACILITY NUMBER:
486830786
ADMINISTRATOR:CABE, ROMEOFACILITY TYPE:
740
ADDRESS:900 DAWNVIEW WAYTELEPHONE:
(707) 447-1920
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 5DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Romeo CabeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is unable to properly communicate with residents due to language barrier
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Our Lady of Peace Home Care for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Romeo Cabe, and was granted access into the facility.

During the course of the investigation, LPA reviewed resident records, facility records, interviewed staff, residents in care, a witness and an outside provider.

Complaint alleges that staff is unable to properly communicate with residents due to language barrier. During the opening of the complaint on March 23, 2023, LPA interviewed three staff members and had no issue communicating with staff members. Furthermore, LPA also observed an outside provider communicating with the facility in a professional manner consistent with communication that is understandable.

(Report continued on LIC 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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 4
Control Number 21-AS-20230320083448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OUR LADY OF PEACE HOME CARE
FACILITY NUMBER: 486830786
VISIT DATE: 04/10/2023
NARRATIVE
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This agency has investigated the complaint alleging that staff is unable to properly communicate with residents due to language barrier. 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4