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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 100408901
Report Date: 03/27/2025
Date Signed: 04/01/2025 09:57:05 AM

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
03/18/2025 and conducted by Evaluator Rachel A Bruce
COMPLAINT CONTROL NUMBER: 24-AS-20250318134230
FACILITY NAME:GARDEN MANOR INC.FACILITY NUMBER:
100408901
ADMINISTRATOR:BLACK, JOANFACILITY TYPE:
740
ADDRESS:4983 E. OLIVETELEPHONE:
(559) 255-8650
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:49CENSUS: 35DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joanna Tilghman, Administrative Assistant TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility MAR is incomplete
INVESTIGATION FINDINGS:
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On March 27, 2025 Licensing Program Analyst (LPA) Rachel Bruce met with Administrative Assistant (AA) to deliver the finding on the above allegation

During the course of this complaint investigation LPA interviewed staff and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility records substantiate the resident in question did receive two doses of medication as prescribed despite the Medication Administration Record only documenting the morning dose. Facility was made aware of the documentation issue and remedied the oversight immediately. The prescribing doctor was notified and was confident the error had been corrected and was confident the staff at Garden Manor would be diligent in ensuring signatures document the provision of medication to the client. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Rachel A BruceTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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-20250318134230
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: GARDEN MANOR INC.
FACILITY NUMBER: 100408901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2025
Section Cited
CCR
87465(a)(6)
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Incidental Medical Care (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by
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AA has indicted that the documentation error was remedied and pill audit confirmed the patient did indeed recieve the prescribed medication appropriately. AA has reviewed the medication dispensing procedures with staff specifically to check everytime what the prescrption states and to ensure their intials are documented appropriately.
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Staff dispensed medication without signing the documentation to indicate when the dosage was administered. This poses an immediate risk to the health and safety of the resident in care.
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Plan of correction to be cleared at today's visit.
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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: Rachel A BruceTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
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