107203197-5-20-2021-24-AS-SPIY-C47Q4M-20210621115032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203197
Report Date: 05/20/2021
Date Signed: 05/20/2021 05:02:41 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
05/14/2021 and conducted by Evaluator See Moua

COMPLAINT CONTROL NUMBER: 24-AS-20210514153608

FACILITY NAME:	VINTAGE GARDENS		FACILITY NUMBER:	107203197
ADMINISTRATOR:	GEBBIA, LOUIS		FACILITY TYPE:	740
ADDRESS:	540 S. PEACH		TELEPHONE:	(559) 252-4036
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	158	CENSUS: 70	DATE:	05/20/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Louis Gebbia, Administrator Sonja, Wellness Coordinator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained an unwitnessed fall while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S. Moua conducted an unannounced complaint inspection on this date. LPA met with Administrator Louis and stated the purpose of the visit. LPA discussed the allegation.

LPA interviewed staff and resident. Incident report of what happened was received by the Department. Resident confirmed she fell while walking to the phone. Resident confirmed staff assisted and care was sought after the incident. Records reviewed. Based on interviews conducted, resident's fall was not because of lack of care or supervision, and the allegation is Unfounded. Exit interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See Moua	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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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