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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803337
Report Date: 11/03/2022
Date Signed: 11/03/2022 09:59:16 AM

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 David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20221025120741
FACILITY NAME:BUCKINGHAM RESIDENTIAL CARE HOMEFACILITY NUMBER:
496803337
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:954 BUCKINGHAM DRIVETELEPHONE:
(707) 888-5259
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 5DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Noel MarayagTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not fingerprint cleared and/or associated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of opening the investigation of this complaint. LPA was meet by caregiver and toured the facility. At the time of the visit, five resients and one caregiver were present. LPA determined that caregiver, S1, is not associated to facility. Based upon statements and record review, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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
Control Number 21-AS-20221025120741
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: BUCKINGHAM RESIDENTIAL CARE HOME
FACILITY NUMBER: 496803337
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2022
Section Cited
CCR
87355(e)(2)
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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement has not been met as evidenced by: Based upon
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Administration shall remove S1 from the facility or associate S1 to the facility as required by Title Twenty Two regulations. Proof of compliance due to CCL by POC date in order to clear the deficiency.
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statements and record review, S1 who is not associated to the facility and has been working as caregiver at facility. This poses an immediate risk to the safety and personal rights of the residents 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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2