Complaint Investigation Report

A witness reported that individuals were residing at the facility who were not background checked on the Guardian System. In an unredacted Sonoma County Sheriff’s Incident/Investigation Report for case #SD251002013 a party involved provided their home address as “1386 Sanders Road, Windsor CA 95492”. This is the same address as the facility. In an interview with this involved party (identified as W1), W1 confirmed that they were residing at the facility. The witness (W1) stated that they had been living at the facility for several months and that they left through the back door when the LPA arrived to do the annual inspection on 9/9/2025. LPA confirmed that W1 was not background cleared through the Guardian Background Check System as required by regulation. 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 1, are being cited on the attached 9099D.

Complaint alleges staff are violating the client’s Personal Rights. A witness alleges that staff denied a client access to food; that they were verbally abusive to clients and that clients were denied access to food. Former clients interviewed were asked if facility staff were ever mean to them or if they were ever treated derogatorily by staff members. All former clients interviewed stated that they were never spoken to or treated in a derogatory manner. A witness reported that the facility’s dogs are nipping at the clients. During the facility’s annual inspection on 9/9/2025, LPA reviewed clients’ files and did not find any physicians after visit summaries indicating that treatment was provided for a dog bite. Additionally, LPA reviewed Incident Reports submitted by the facility for the previous five (5) years and did not find any instances of a facility dog biting a client. LPA interviewed former clients of the facility. Former clients stated that they were never bitten or nipped at by facility dogs. Complaint alleges that staff denied a client access to food. A witness reported that facility staff are not allowing clients access to their food in the facility kitchen. In interviews with former clients, LPA was told that there were occasions when they were not allowed to go into the kitchen. When asked if they were given enough to eat, clients responded that they were given enough food to eat but that still were times when they were not allowed to go into the kitchen. Facility staff did not respond to requests for interviews. Based on LPA’s interviews, 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 1, are being cited on the attached 9099D.