100400070-2-17-2021-24-AS-AXIG-BYJQZB-20210224113628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100400070
Report Date: 02/11/2021
Date Signed: 02/17/2021 11:45:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/12/2021 and conducted by Evaluator See Moua

COMPLAINT CONTROL NUMBER: 24-AS-20210112162406

FACILITY NAME:	CALIFORNIA ARMENIAN HOME		FACILITY NUMBER:	100400070
ADMINISTRATOR:	PAUL ROCHA		FACILITY TYPE:	741
ADDRESS:	6720 E KINGS CANYON RD		TELEPHONE:	(559) 251-8414
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	332	CENSUS: 174	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	04:11 PM
MET WITH:	Paul Rocha, Administrator		TIME COMPLETED:	04:12 PM

ALLEGATION(S):

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9

Facility does not have a care plan for residents

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See Moua	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/12/2021 and conducted by Evaluator See Moua

COMPLAINT CONTROL NUMBER: 24-AS-20210112162406

FACILITY NAME:	CALIFORNIA ARMENIAN HOME		FACILITY NUMBER:	100400070
ADMINISTRATOR:	PAUL ROCHA		FACILITY TYPE:	741
ADDRESS:	6720 E KINGS CANYON RD		TELEPHONE:	(559) 251-8414
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	332	CENSUS: 174	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	04:11 PM
MET WITH:	Paul Rocha, Administrator		TIME COMPLETED:	04:12 PM

ALLEGATION(S):

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9

Facility kitchen is not clean
Staff made inappropriate comment in front of a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S. Moua conducted a subsequent complaint inspection via telephone due to COVID-19 precautionary measures. LPA spoke with Administrator Paul Rocha, discussed the allegations, and delivered the findings.

Interviews were conducted with facility staff and allegations were denied. Observation of memory care and records reviewed were conducted by the Department. No concerns were observed. Staff denied making inapproprate comment in front of a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were observed. Exit Interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See Moua	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2