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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801807
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:57:47 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
10/04/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241004090128
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: 5DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:CaregiverTIME COMPLETED:
03:12 PM
ALLEGATION(S):
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Staff hit resident in care
INVESTIGATION FINDINGS:
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At approximately 1:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegation and met with caregiver. Angelica Martinez, Administrator contact by phone. Admin was not available to come to facility. Admin gave permission for caregiver to sign.

Complaint alleges staff hit resident in care. Complainant states that facility Administrator pushed and hit resident (R1). During investigation, LPA reviewed R1’s chart notes dated between 1/1/2024 through 10/1/2024 and interviewed staff and residents. LPA’s review of R1’s chart notes indicate four [4] noted incidents of aggression and two [2] incidents of hitting staff. Three [3] out of three [3] staff interviewed report to LPA that resident has episodes of aggression and has lashed out and hit other residents and staff, including the facility Administrator. During investigation, LPA interviewed resident R2, R2 indicated that R1 has hit them and also has hit resident R3.

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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 5
Control Number 21-AS-20241004090128
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: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807
VISIT DATE: 10/29/2024
NARRATIVE
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Continued from 9099...

During investigation, LPA reviewed outside agency statement which reports that resident has history of being verbally and physically aggressive towards facility staff, a history of making false allegations, and that resident is noted to be an unreliable historian. So, 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 allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/04/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241004090128

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: 5DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:CaregiverTIME COMPLETED:
03:12 PM
ALLEGATION(S):
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Staff did not prevent resident from leaving the facility unassisted
INVESTIGATION FINDINGS:
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At approximately 1:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegation and met with caregiver. Angelica Martinez, Administrator contact by phone. Admin was not available to come to facility. Admin gave permission for caregiver to sign.

Complaint alleges staff did not prevent resident from leaving the facility unassisted. Complainant states on 10/2/24 R1 was found wandering about 20-30 minutes from home, was screaming and unable to follow directions. On 10/2/24 R1 asked to sit out in the front yard on the grass. Facility staff was there in front yard observing R1 when another resident arrived home from an appointment. The staff observing R1 briefly escorted the returning resident inside the facility. It was during this time that R1 left the front yard of the facility.


Continued on 9099A(C)...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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 5
Control Number 21-AS-20241004090128
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: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807
VISIT DATE: 10/29/2024
NARRATIVE
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Continued from 9099A...

During investigation, LPA reviewed R1’s care plans. R1’s care plans indicate that the resident is independent and likes to go on walks and enjoys being outside. During investigation, Admin reported to LPA that she knows R1 likes to be outside and go on walks, it helps to de-escalate R1’s aggression, among other positive benefits. As a safety measure and precaution, Admin pro-actively purchased a GPS tracker for R1 to wear when going on walks so that if R1 is gone longer than 10 minutes, R1’s location can be quickly determined. Admin purchased this GPS with family of R1’s approval.

During investigation, LPA reviewed the four [4] most recent physician’s reports and care plans for R1. Three [3] out of four [4] of the physician’s reports reviewed indicate that the resident can leave the facility unassisted, for short walks outside. However, the most recent physician’s report indicates a change in R1’s assessment of leaving the facility unassisted, the most recent physician’s report indicates that the resident cannot leave the facility unassisted. Admin advised LPA that Admin must have accidentally overlooked this change in the most recent physician’s report section that indicates that the resident cannot leave the facility unassisted. So, the caregiver allowed R1 to briefly be outside unsupervised, as the caregiver was not aware of the change in R1’s physician report.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20241004090128
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: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Facility to submit LIC9098 self-certifying they have reviewed all of the most recent physician reports of residents and will ensure all staff are aware of the abilities and needs of all residents.
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This requirement was not met by licensee as evidenced by: elopement of R1, which poses an immediate potential health, safety, and personal rights risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5