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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 100408901
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:05:43 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
08/18/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210818085701
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: 49DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Administrator, Joan BlackTIME COMPLETED:
12:51 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide resident adequate supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Joan Black

Based on interview and records review it was determined that R1 had witnessed falls on 08/12/2021 and 08/13/2021. On each occasion, facility staff initiated emergency services and responded appropriately.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies issued. An exit interview was conducted. As a COVID-19 precautionary measure, a copy of this signed report will be provided via email and an electronic read receipt confirms receiving this document.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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
08/18/2021 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210818085701

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: 49DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Administrator, Joan BlackTIME COMPLETED:
12:51 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries (burns) while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Joan Black.

Based on interviews and records review it was determined that R1 had a witnessed fall as a result of having multiple seizures and R1 landed on hot asphalt. S1 witnessed the incident and placed R1 on R1’s right side per Emergency Services dispatch instructions. S2 retrieved a blanket and pillow to put underneath R1. Paramedics arrived to assess R1. Per Ambulance records, it is not uncommon for patients to sustain burns rapidly while on asphalt on hot days. Per the weather report, on the day of the incident it was 104 degrees F.

The Department has investigated the complaint alleging: Resident sustained injuries (burns) while in care. We have found that the complaint was UNFOUNDED.

No deficiencies issued. An exit interview was conducted. As a COVID-19 precautionary measures, a copy of this signed report will be provided via email and an electronic read receipt confirms receiving this document.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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