<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107201295
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:59:12 AM

Unsubstantiated


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
07/21/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20220721084033
FACILITY NAME:MARTIN'S HOME-HOMSYFACILITY NUMBER:
107201295
ADMINISTRATOR:MARTIN, WILMAFACILITY TYPE:
735
ADDRESS:345 NORTH HOMSY AVENUETELEPHONE:
(559) 412-8903
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 4DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Administrator, Wilma Martin TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an injury while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted interviews and reviewed records. Based on interviews conducted with Regional
Center, residents, and facility staff, R1 has an unsteady gait and is prone to falls while walking and in seated position.

Facility staff appeared to have taken the proper protocol to ensure resident has necessary protective equipment to avoid or lesson the harm of injury to client. R1 was also taken to care provider to determine if any health issues were leading to/or resulted in these incidents.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the
alleged violations did occur; therefore, the allegations are Unsubstantiated.

Exit interview completed. Report signed on sight by Administrator and printed copy provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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