Complaint Investigation Report

486804286-3-11-2026-21-AS-KMOA-DSBNQQ-20260319104018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SANTA ROSA RO , 1450 NEOTOMAS AVENUE, STE. 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

12/24/2025 and conducted by Evaluator Ethel Contreras

COMPLAINT CONTROL NUMBER: 21-AS-20251224140600

Resident eloped from the facility due to lack of care and supervision from staff

Licensing Program Analyst (LPA) Ethel Contreras arrived at this facility unannounced to deliver findings for the above allegation. LPA met with administrator Stephen Ngata. During the course of the investigation, LPA interviewed staff, made observations, and reviewed records.

Complaint alleges resident eloped from the facility due to lack of care and supervision from staff. On 10/30/2025 Community Care Licensing (CCL) received an incident report regarding an elopement that occurred on 10/29/2025. LPA conducted a case management visit on 11/06/2025 regarding the current allegation. During the Case Management Visit, LPA gathered documents and conducted interviews. Facility was cited and issued a Civil Penalty for $500 per HSC 15489(c)(3) due to facility not providing the services necessary to meet client’s needs as evidenced by lack of supervision which led to an elopement from facility. No other elopement or lack of supervision occurred by facility since being cited on 11/06/2025. 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.This allegation has already been cited and addressed during Case Management Visit of 11/6/2025.