107202478-12-12-2024-24-AS-BCHN-DDVVFS-20250214152423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107202478
Report Date: 12/11/2024
Date Signed: 12/12/2024 08:52:15 AM

Unsubstantiated

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
08/20/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240820175233

FACILITY NAME:	FILLMORE CHRISTIAN GARDEN		FACILITY NUMBER:	107202478
ADMINISTRATOR:	MILLY, INTHONE		FACILITY TYPE:	735
ADDRESS:	4826 E. FILLMORE		TELEPHONE:	(559) 252-6825
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	27	CENSUS: 19	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Administrator Inthone Milly		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not inform resident’s responsible party of an incident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/11/2024, Licensing Program Analyst (LPA) V Gorban conducted an unannounced complaint inspection at 1000 hours. LPA met with Licensee Inthone Milly. The purpose of this visit is to deliver the finding of the investigation completed by the Department.
LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

Allegation: Staff did not inform resident’s responsible party of an incident.
Based on the facility administrator and staff interviews conducted, facility documentation obtained and reviewed, and the information received during this investigation staff S1 reported incident to the appropriate agencies by phone. “ 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.

Exit interview conducted, report signed and its copy provide for facility records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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 1