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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200790
Report Date: 03/03/2023
Date Signed: 03/08/2023 02:38:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
03/02/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230302103400
FACILITY NAME:CLOVIS QUALITY CARE IIFACILITY NUMBER:
107200790
ADMINISTRATOR:STAGGS, PATRICIAFACILITY TYPE:
740
ADDRESS:944 N. CHAPEL HILLTELEPHONE:
(559) 322-1220
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:7CENSUS: 5DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Patricia StaggsTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff did not issue resident(s) a 60 day written notice.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a complaint investigation. LPA Hurt met with Licensee Patricia Staggs and explained the purpose of today's visit.

Regarding the allegation Facility staff did not issue resident(s) a 60 day written notice. Licensee Patricia Staggs stated she did give a written notice to clients infomring them of her intent to sell the facility. Licensee Patricia did state she gave the residents the written notice on January 31, 2023 not within the 60 day required period. LPA Hurt reviewed a written notice provided to residents notifying them of the intent to transfer facility ownership, but it was not dated. Licensee Patricia Staggs did not notify State Licensing of their intent to transfer ownership.

Continued..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 3
Control Number 24-AS-20230302103400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CLOVIS QUALITY CARE II
FACILITY NUMBER: 107200790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
HSC
1569.682(a)(1)(B)(2)
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§1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties (a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license, as described in subdivision (a), (b), or (f) of Section 1569.19, or a change of use of the facility pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following:(1) Prepare, for each resident, a relocation evaluation of the needs of that resident, which shall include both of the following:(A) Recommendations on the type of facility that would meet the needs of the resident based on the current service plan.(B) A list of facilities, within a 60-mile radius of the resident’s current facility, that meet the resident’s present needs.(2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The following requirement has not been met as evidenced by:
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Licensee Patricia Staggs will submit all required paperwork notifying of intent to change ownership, along with notices given to facility residents to state Licensing by 03/17/2023 POC date.
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The Licensee Patricia Staggs did not give residents 60 day notice of facility closure which poses a potential health, safety, or personal rights risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230302103400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CLOVIS QUALITY CARE II
FACILITY NUMBER: 107200790
VISIT DATE: 03/03/2023
NARRATIVE
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..Continued

Based on records reviewed, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

The following deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Licensee Patricia Staggs, and a copy of this report along with Appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3