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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801807
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:20:59 PM

Substantiated


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
10/25/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20221025101410
FACILITY NAME:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 6DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Staff, Marbella MatusTIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not fingerprint cleared and/or associated.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/15/2022 to deliver complaint findings regarding the allegation above. Administrator, Angelica Martinez was not available but was notified of findings over the phone and agreed to have staff sign complaint report.

LPA investigated the allegation that staff were not fingerprint cleared and/or associated. During the initial inspection on 11/03/2022 LPA reviewed staff records, personnel reports, staff sign in sheets, and Guardian roster. Record review revealed that Staff 1 (S1) was fingerprint cleared and associated to licensee’s other facility but not Yerba Buena Residential Care Home. S1 has since been associated to the facility. The preponderance of evidence standard has been met; therefore, the above allegation is substantiated.

No deficiencies cited. LPA has assessed a technical violation regarding criminal record clearance transfers. Exit interview conducted with staff, Marbella Matus. Report emailed to administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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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