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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206271
Report Date: 09/15/2020
Date Signed: 09/15/2020 04:49:42 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
02/26/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20200226121428
FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107206271
ADMINISTRATOR:HUNT, STEVENFACILITY TYPE:
740
ADDRESS:14280 W. STANISLAUS STREETTELEPHONE:
(559) 842-7727
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:34CENSUS: 19DATE:
09/15/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Steven HuntTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained injuries due to an unwitnessed fall
INVESTIGATION FINDINGS:
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Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this inspection by phone.

On this date Licensing Program Analyst (LPA) K. Mcclurg conducted a Complaint tele-visit with Administrator Steven Hunt.

Allegation reviewed. Interviews conducted. Records reviewed. Persons interviewed indicated they responded immediately to resident's signal of distress. 911 called & was taken to hospital for further evaluation. Resident returned to facility same day.


Continued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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-20200226121428
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: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107206271
VISIT DATE: 09/15/2020
NARRATIVE
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Continued from page 1.

The Department has investigated the allegation & determined that it is unsubstantiated.

Exit interview conducted with Administrator Steven Hunt. Report provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2