216803604-9-24-2026-21-AS-VBEI-DYDSYM-20260929141744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803604
Report Date: 09/24/2026
Date Signed: 09/24/2026 02:06:52 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
06/09/2026 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20260609072603

FACILITY NAME:	LONG LIFE LIVING INC III		FACILITY NUMBER:	216803604
ADMINISTRATOR:	CHANG, FAYE		FACILITY TYPE:	740
ADDRESS:	36 MT. FORAKER DRIVE		TELEPHONE:	(415) 479-4890
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2026
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Staff Member, Tess Tuviera, and Designated Representative, Justine Herrera		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Lack of staff supervision resulting in resident sustaining a fracture while in care
Staff did not address resident's fall risk

INVESTIGATION FINDINGS:

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At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Staff Member, Tess Tuviera. Designated Representative, Justine Hererra, arrived during visit at approximately 9:30AM.

During the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegations were investigated, "Lack of staff supervision resulting in resident sustaining a fracture while in care," and "Staff did not address resident's fall risk." Complaint alleged that that Resident 1 (R1) was observed to have a bruise on their right leg when being assisted with dressing. Report further stated that (R1) was found to have a leg fracture and had a history of falls.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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-20260609072603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LONG LIFE LIVING INC III	FACILITY NUMBER: 216803604
	VISIT DATE: 09/24/2026

NARRATIVE

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Continued from LIC9099

"Lack of staff supervision resulting in resident sustaining a fracture while in care" - Interviews were conducted with Involved Parties. 2 of 2 interviews revealed that R1 had severe osteoporosis and stated the medical professionals informed them that R1's bones were "like glass." Per interviews, because of the severity of R1's bones, they were told that any small bump could have caused the fracture. Interviews also revealed that while R1 had a history of falls, they did not require one-on-one supervision and did not need a caregiver with them at all times.

Interview conducted with Administrator revealed that R1 had been observed on the morning of 05/30/2026 to have a swollen knee and couldn't get out of bed. Facility sent R1 to the hospital for further evaluation and it was found that R1 had a fracture. Per Administrator, based on where the fracture was located, the doctor didn't think that R1 had a fall and said that R1 had a severe case of brittle bones. Administrator further revealed that the doctor said that due to R1's brittle bones, R1 could have sustained their fracture just by knocking it against something hard like their bed or their bedroom wall.

"Facility failed to address R1's fall risk" - Interviews were conducted with Involved Parties. 2 of 2 interviews revealed that R1 had a history of falls but that R1 did not require one-on-one supervision and did not need a caregiver with them at all times. R1's care plans were reviewed. Previous care plans for R1 stated that they were able to ambulate using a walker and required supervision while transferring or walking. R1's care plan for 2026 stated that R1 was a fall risk but was able to get around their bedroom somewhat independently by using their walker. This care plan also stated that they preferred to stay in bed or in their room. This care plan did not state that one-on-one supervision was required.

Based on documents reviewed, interviews conducted, and observations made, these allegations are Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Designated Representative. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

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