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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801090
Report Date: 12/28/2021
Date Signed: 12/28/2021 11:24:24 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211206115500
FACILITY NAME:HANNA HOUSE RIDLEYFACILITY NUMBER:
496801090
ADMINISTRATOR:HANNA, DAVIDFACILITY TYPE:
740
ADDRESS:1840 RIDLEY AVENUETELEPHONE:
(707) 591-0980
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:28CENSUS: 23DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kerrie HannaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff do not allow resident to leave the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Kerrie Hanna and discussed the findings. During the course of this investigation statements were taken, records were obtained and reviewed, and site visits conducted. The following determinations have been made: Physician's Report for Residential Care Facilities for the Elderly, dated 08/30/2021, for Resident #1 states, in part: (Able to Leave Facility Unassisted?) "Only allowed to go out in front of house;" Facility is fully fenced with delayed egress gates and provides spacious areas for residents in side of the fenced area; R1 complains that R1 is not allowed by staff to leave the property unaccompanied; Staff actions regarding R1's ability to leave the facility are in response to, and in compliance with, Physician's orders and, therefore, do not reflect an independent decision made by staff. Based upon the records reviewed, statements obtained, and site inspections made, this complaint is UNFOUNDED, meaning that the allegation is false and without a reasonable basis. The allegation is DISMISSED.

No Citation issued. Report left at facility.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211206115500

FACILITY NAME:HANNA HOUSE RIDLEYFACILITY NUMBER:
496801090
ADMINISTRATOR:HANNA, DAVIDFACILITY TYPE:
740
ADDRESS:1840 RIDLEY AVENUETELEPHONE:
(707) 591-0980
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:28CENSUS: 23DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kerrie HannaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Kerrie Hanna and discussed the findings. During the course of this investigation statements were taken, records were obtained and reviewed, and site visits conducted. The following determinations have been made: Complainant alleges that on or about 12/05/2021 R1 was pushed by Facility Administrator (FA); FA states that R1 initiated aggression by pushing FA, swearing at him, at raising arms in a threatening manner; FA states he grabbed R1’s wrists in an defensive mode until R1 calmed down; Investigation of the incident by Santa Rosa Police Department was closed as unfounded; No credible witnesses to the incident have been identified. Although the allegation may be true, based upon the statements and documents reviewed, there is not a preponderance of evidence to prove the allegation is, or is not, true. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2