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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107201156
Report Date: 06/01/2020
Date Signed: 06/01/2020 01:14:24 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
03/06/2020 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200306153444
FACILITY NAME:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR:EDWARDS, DEANNEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:270CENSUS: 241DATE:
06/01/2020
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Deanne EdwardsTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained fracture while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) M. Medina contacted the facility on this date telephonically due to COVID-19 precautionary measures. LPA spoke with Deanne Edwards and reviewed the allegations.

The Department found that on 3/0/3/20, R1 was found laying on the floor inside facility by staff and trasnported by EMS to hospital for medical care. During investigation resident file and medical records for R1 were reviewed. Review of R1 death certificate listed cause of death as Alzheimer's disease. This complaint is Unsubstantiated.

Findings delivered. Exit interview conducted.

No deficiencies cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2020
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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