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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107201085
Report Date: 08/13/2020
Date Signed: 08/13/2020 03:59:42 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
09/30/2019 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20190930160412
FACILITY NAME:GARDEN TERRACE ASSISTED LIVING IIIFACILITY NUMBER:
107201085
ADMINISTRATOR:HERGENROEDER, STEVE & JULIFACILITY TYPE:
740
ADDRESS:1760 E. CHENNAULTTELEPHONE:
(559) 297-7530
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
08/13/2020
UNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Julie Hergenroeder, LicenseeTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect lead to residents death
Staff left resident in bed resulting in multiple pressure injuries
Residents did not receive timely medical attention
Staff did not notify residents authorized representative of incidents
Residents hygenic care needs were not met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/13/2020, Licensing Program Analyst (LPA), L. Salazar, contacted Licensee, Julie H to deliver findings on the above allegations. Due to COVID-19 and precautionary measures, this visit was conducted via tele inspection.

During the course of the investigation, LPA conducted record reviews, interview, Licensee and Staff. Staff Interviews did not reveal any staff that has threatened residents LPA did not interview residents due to cognitive status. LPA conducted a physical tour of the facility when complaint was opened.

Record Reviews and physical plant inspection revealed current LIC 602 for Resident R1, medication log for Resident R2, facility plumbing was free from obstruction and operational. LPA observed residents engaging in activities at the time of inspection. Based on the information received, the allegations are UNFOUNDED.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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
09/30/2019 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20190930160412

FACILITY NAME:GARDEN TERRACE ASSISTED LIVING IIIFACILITY NUMBER:
107201085
ADMINISTRATOR:HERGENROEDER, STEVE & JULIFACILITY TYPE:
740
ADDRESS:1760 E. CHENNAULTTELEPHONE:
(559) 297-7530
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
08/13/2020
UNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Julie Hergenroeder, LicenseeTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaging residents medication
Medication is not properly stored
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/13/2020, Licensing Program Analyst (LPA), L. Salazar, contacted Licensee, Julie H to deliver findings on the above allegations. Due to COVID-19 and precautionary measures, this visit was conducted via tele inspection.

During the course of the investigation, LPA conducted record reviews, interviews and physical plant inspection. Interviews with staff and licensee revealed the medication management is currently being done annually as regulated. LPA did not interview residents due to cognitive status. LPA conducted a physical tour of the facility when complaint was opened.

Record Reviews and physical plant inspection revealed LPA's observation of a bag of medications in medication closet for a resident that recently passed. Medication Destruction log was observed. Medication logs and LIC 602 for Resident R1 was observed. Incident reports for R1 were observed. Based on the information received, the allegations are UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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