100400544-7-23-2024-24-AS-MHON-D7JLAJ-20240726083512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100400544
Report Date: 07/23/2024
Date Signed: 07/23/2024 10:00:50 AM

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
03/18/2024 and conducted by Evaluator Alexandria Walton

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240318085012

FACILITY NAME:	TERRACES AT SAN JOAQUIN GARDENS, THE		FACILITY NUMBER:	100400544
ADMINISTRATOR:	CASE, ALEXIS		FACILITY TYPE:	741
ADDRESS:	5555 NORTH FRESNO STREET		TELEPHONE:	(559) 439-4770
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	652	CENSUS: 330	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Director of Assisted Living and Wellness, Valerie Epps		TIME COMPLETED:	10:13 AM

ALLEGATION(S):

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Resident sustained 2 stage 4 pressure injuries, fractured pelvis, and internal bleeding due to staff neglect
Facility does not have enough staff to meet residents needs
Facility staff failed to conduct appraisals to meet resident’s change of condition

INVESTIGATION FINDINGS:

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On 07/23/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and reqeusted to meet with the Administrator. LPA met with Director of Assisted Living and Wellness, Valerie Epps

Based on interviews and records review, R1 sustained a witnessed fall resulting in R1 sustaining injuries and staff seeking emergency medical treatment. Due to R1's level of independence it was determined that facility staff could not have prevented the fall. Review of records revealed that no pressure wounds were observed upon admission to the hospital. R1 was transferred to another hospital for a higher level of care, where R1 was examined and a pressure wound was observed. R1 was later discharged to a skilled nursing facility where the pressure wound worsened.

The Department has investigated the allegations: Resident sustained 2 stage 4 pressure injuries, fractured pelvis, and internal bleeding due to staff neglect, Facility does not have enough staff to meet residents needs, Facility staff failed to conduct appraisals to meet resident’s change of condition. CONTINUED TO 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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-20240318085012

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: TERRACES AT SAN JOAQUIN GARDENS, THE	FACILITY NUMBER: 100400544
	VISIT DATE: 07/23/2024

NARRATIVE

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The Department has found that the allegations are UNSUBSTANTIATED. 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.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Director of Assisted Living and Wellness, Valerie Epps, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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