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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107203197
Report Date: 12/30/2021
Date Signed: 12/31/2021 10:34:14 AM



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
10/15/2021 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211015093738
FACILITY NAME:VINTAGE GARDENSFACILITY NUMBER:
107203197
ADMINISTRATOR:GEBBIA, LOUISFACILITY TYPE:
740
ADDRESS:540 S. PEACHTELEPHONE:
(559) 252-4036
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:158CENSUS: 54DATE:
12/30/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Wellness Director, Sonja HerbertTIME COMPLETED:
01:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced visit. LPA Williams met with Wellness Director, Sonja Herbert and discussed the purpose of the visit.

LPA Williams interviewed the Wellness Director, three residents, and toured the facility. Resident 1 (R1) was not available to interview.

According to facility report dated 10/18/2021, R1 was found by staff lying on the floor near the elevator. R1 had her walker when staff arrived to the incident. Emergency Medical Services was contacted for assessment.

During the tour, LPA Williams observed staff walking the halls supervising residents and checking in on residents in their bedrooms.

*Continued on LIC9099C*

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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
Control Number 24-AS-20211015093738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VINTAGE GARDENS
FACILITY NUMBER: 107203197
VISIT DATE: 12/30/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
According to Resident 2, 3, and 4, they are checked on by staff multiple times a day while in their bedrooms. All three reported observing staff in hallways and common areas assisting residents. LPA Williams observed the residents wearing pendants around their necks that are used to request assistance from staff.

LPA Williams interviewed Witness 1 (W1) via phone. W1 visited R1 approximately every two weeks between 5/2017 and 3/2020 and started visiting again approximately 9/2021 During the visits, W1 observed staff check on R1 approximately every 30-60 minutes. W1 reported no concerns regarding staff supervision.

Based on interviews and record reviews, 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.

An exit interview was conducted and a copy of this report will be provided via e-mail..

.


SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2