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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107203215
Report Date: 01/20/2021
Date Signed: 01/20/2021 10:20:29 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
12/29/2020 and conducted by Evaluator See Moua
COMPLAINT CONTROL NUMBER: 24-AS-20201229092226
FACILITY NAME:ROYAL CAREFACILITY NUMBER:
107203215
ADMINISTRATOR:RIGON, RUDY G.FACILITY TYPE:
740
ADDRESS:2768 PURVIS AVE.TELEPHONE:
(559) 324-8792
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 1DATE:
01/20/2021
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Aurora Rigon, Administrator TIME COMPLETED:
10:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff refused to accept resident back from the hospital.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) S. Moua contacted the facility via telephone to deliver findings due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the complaint allegation and finding with Administrator Aurora Rigon.

Facility staff, S1, was interviewed about what happened. It was confirmed that S1 contacted the CCL RO for guidance and instructions as R1, referenced in the complaint, was returning with an oxygen tank and higher level of care. Facility followed guidance that was provided and was working with the hospital on appropriate discharge measures. S1 stated the facility never refused to accept R1 back. Complaint is Unfounded. Exit Interview was conducted.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021
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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