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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 100400070
Report Date: 03/18/2024
Date Signed: 04/03/2024 02:45:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2023 and conducted by Evaluator Lissett Padgett
COMPLAINT CONTROL NUMBER: 24-AS-20231027143209
FACILITY NAME:CALIFORNIA ARMENIAN HOMEFACILITY NUMBER:
100400070
ADMINISTRATOR:PAUL ROCHAFACILITY TYPE:
741
ADDRESS:6720 E KINGS CANYON RDTELEPHONE:
(559) 251-8414
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:392CENSUS: 234DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Paul RochaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Staff do not prevent inappropriate interactions between residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst L. Padgett arrived unannounced to deliver investigative findings on the above allegations. LPA met with Facility Administrator, Paul Rocha and explained the purpose of the visit.
The Department conducted interviews with staff and witnesses and reviewed resident and facility records, including incident reports, resident care notes, physician’s report pertaining to Residents R1 and R2. It was determined that staff did not prevent sexually inappropriate interactions between residents.
Based on the investigation, the preponderance of evidence standard has been met, therefore the allegation, Staff do not prevent inappropriate interactions between residents is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D.
Exit interview was conducted with Administrator and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 24-AS-20231027143209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CALIFORNIA ARMENIAN HOME
FACILITY NUMBER: 100400070
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/22/2024
Section Cited
CCR
84768.2(a)(8)
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87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, ... for the elderly shall have all of the following personal rights: (8) To be free from neglect… intimidation, and verbal, mental, physical, or sexual abuse.
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Licensee will review complaint allegation with staff and submit plan of correction to this LPA by 3/19/2024. Ombudsman will conduct Mandated Reporter (MR) training on 3/28/24 to all staff, Licensee will submit (MR) training roster to this LPA by the following day.
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This requirement was not met as evidenced by:
Based on records reviewed and interviews conducted, staff did not prevent resident (R1) from being inappropriately touched by another resident. This poses an immediate Health and Safety risk to the residents in care.
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 Licensee will provide verification to this LPA that Plan of Correction training was conducted with staff. Licensee will provide detailed report of steps already taken to ensure safety of residents.
Deficiency Dismissed
Type B
03/25/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a) (1)(D) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ... This report shall include the resident's name... nature of event; …Any incident which threatens the welfare, safety or health of any resident...
This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing steps the facility will take to ensure the Reporting requirements are met by the POC due date of 3/25/2024.
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Based on interviews and facility record review it was determined that staff did not inform Licensing and Resident’s responsible parties of an incident of inappropriate interaction between residents.
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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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
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