100400070-5-3-2022-24-AS-SPIY-CE5KC6-20220505074633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100400070
Report Date: 05/03/2022
Date Signed: 05/03/2022 12:31:05 PM

Unsubstantiated

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
12/22/2021 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20211222165036

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:	368	CENSUS: 270	DATE:	05/03/2022
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Paul Rocha		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident fell while in care
Residents not assisted in a timely manner
Staff not responding to residents call button
Facility does not have proper equipment to assist residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facilirt unannounced to deliver the complaint investigation findings. LPA explained the purpose of the visit and the elements of the allegations with Administrator Paul Rocha.

The Department investigated the allegation: Resident fell while in care. The facility submitted a Special Incident Report (SIR) to CCLD reporting that Resident R1 sustained a fall. Based on Records Review of the SIR, Physician’s Report, Facility Assessment and Facility Call System Record, it was determined that even though the resident fell while in care, it was not due to lack of care and supervision provided by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

See LIC9099-C for continuation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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-20211222165036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CALIFORNIA ARMENIAN HOME	FACILITY NUMBER: 100400070
	VISIT DATE: 05/03/2022

NARRATIVE

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The Department investigated the allegation: Residents not assisted in a timely manner. Based on interview of facility staff and residents as well as record review of the facility call system log Resident R1’s pendant was temporarily out of order on 12/1/21 and replaced on 12/2/21. The log does not show that R1 used the call system on 12/1/21. Facility notes recorded that once the facility was notified that R1 needed assistance, a facility Nurse responded and assessed R1 per protocol. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

The Department investigated the allegation: Staff not responding to residents call button. Based on interview of facility staff and resident R1 as well as record review of the facility call system log, it is unable to be determined what time or if the resident used the pendant requesting assistance. The call system log did not record that R1 used the pendant requesting assistance on 12/1/21 at all. R1’s pendant was replaced on 12/2/21. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

The Department investigated the allegation: Facility does not have proper equipment to assist residents. Based on observation of residents in their private apartments as well as interviews of identified residents and staff, the Department did not find that the facility has not provided proper equipment. Based on record review of the identified resident’s files, it was not determined that the facility had not provided equipment as ordered by Physician or as determined in facility assessment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

A copy of this report was provided and an exit interview was conducted with Administrator Paul Rocha.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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