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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803839
Report Date: 07/20/2022
Date Signed: 07/20/2022 05:50:14 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
07/18/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220718080450

FACILITY NAME:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 6DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Staff do not follow proper COVID mask guidance-staff wearing masks inappropriately
INVESTIGATION FINDINGS:
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LPA Dina Alviso conducted a complaint inspection, on 7/20/22 at approximately 3:35pm, and met with Administartor Emelita Guzman. LPA observed two other staff/caregivers on duty during the inspection. The LPA was screened upon entry, temperature taken, covid symptom questions asked, and LPA observed that all information was logged.
The LPA observed all three (3) staff on duty wearing masks but one staff (S1) was observed to be wearing a mask that is very large for them, and the mask was observed to be falling repeatedly under their nose, fully exposing their nostrils. The mask does not fit appropriately and does not meet the mandated mask requirements. This deficiency will be cited, 87468.1(a)(2) Personal Rights of Residents in All Facilities-see LIC9099D. Civil Penalty assessed at $250.. Based on LPA's observations during the inspection the allegation of "staff do not follow proper COVID mask guidance-staff wearing masks inappropriately" is substantiated. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Appeal Rights Given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
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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Control Number 21-AS-20220718080450
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: FAMILY HOUSE
FACILITY NUMBER: 496803839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee to ensure all staff are in compliance with the mask mandate as required; Licensee to ensure that their mask as well as all staffs masks fit as required, and are worn appropriately at all times per the mask mandate.
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This requirement was not met per LPA's observation of staff's(S1) mask not fitting them appropriately, it was very large and kept falling under the staff's nose, fully exposing their nostrils. This is not in compliance with the mask guidelines and mask mandate. This is an immediate risk to health and safety and/or immediate risk to personal rights of the residents. CP assessed at $250.
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Submit facility's plan in ensuring all staff, including Licensee, wears masks that fit appropriately and ensuring staff are in compliance with the mask mandate at all times. POC due 7/21/22.at all timesnd are
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
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