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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206271
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:52:04 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
12/30/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20201230164555
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: 27DATE:
07/28/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Steven HuntTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident suffered falls resulting in a fracture.
Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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A Complaint visit was conducted on the date & times indicated above by LPA K. Mcclurg. LPA met with Administrator (Admin) Steven Hunt. LPA reviewed the purpose of the visit Admin.

The Department reviewed facility records & conducted interviews with facility personnel. The Department has investigated the above allegations & determined them to be substantiated

Deficiency issued. Deficiency cleared @ time of visit.
Exit interview conducted with Admin. Report Provided.
Substantiated
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: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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-20201230164555
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical care appropriate to the conditions and needs of residents.
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Facility conducted staff training regarding the necessity of contacting 911 without delay when appropriate.
Deficiency cleared.
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Resident 1 (R1) was diagnosed with hip fracture in relation to fall. Facility delayed contacting 911 at the time of incident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2