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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803759
Report Date: 07/26/2023
Date Signed: 08/10/2023 03:08:21 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
06/21/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230621090228
FACILITY NAME:NATASHA'S HOMEFACILITY NUMBER:
496803759
ADMINISTRATOR:GLENN VARGASFACILITY TYPE:
740
ADDRESS:3365 PETALUMA HILL RDTELEPHONE:
(650) 270-3030
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:3CENSUS: 3DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Leonardo Dela CruzTIME COMPLETED:
02:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged residents medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This report is an amended revision from original complaint report incorrectly dated 7/26/2023 - Facility visit was completed 7/27/2023.*

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Licensee, Leonardo Dela Cruz

Staff mismanaged residents medication – Complaint alleges that staff gave residents their PM medication in the AM by mistake. Based on Interviews and review of documents LPA was not able to determine that residents were not given their medication at the prescribed time.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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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