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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 100408901
Report Date: 10/14/2020
Date Signed: 10/22/2020 01:17:00 PM



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
09/03/2020 and conducted by Evaluator See Moua
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200903085734
FACILITY NAME:GARDEN MANORFACILITY NUMBER:
100408901
ADMINISTRATOR:BLACK, JOANFACILITY TYPE:
740
ADDRESS:4983 E. OLIVETELEPHONE:
(559) 255-8650
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:49CENSUS: 47DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Joan Black, Administrator TIME COMPLETED:
11:34 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care.
Staff did not allow resident(s) access to telephone.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) S. Moua contacted the facility via telephone to conduct a subsequent complaint inspection due to COVID-19 precautionary measures. LPA discussed the specific allegations with the Administrator. Findings were delivered.

LPA interviewed staff at the facility and R1, referenced directly in the complaint. R1 denied that staff scratched her. R1 confirmed that she scratched herself because of a blister. She added that staff at the facility helped her care for it. She confirmed that she has access to a telephone and can use it anytime. LPA observed no issues when calling the facility. Phone was operational. Based on interviews conducted and observation, the allegations are Unfounded. Exit Interview was conducted. No deficiencies were observed.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
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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