107206271-9-27-2023-24-AS-SMOA-CWNS77-20231016133703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206271
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:12:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
09/08/2023 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20230908170024

FACILITY NAME:	AUTUMN RIDGE ASSISTED LIVING		FACILITY NUMBER:	107206271
ADMINISTRATOR:	JAIME, MORY		FACILITY TYPE:	740
ADDRESS:	14280 W. STANISLAUS STREET		TELEPHONE:	(559) 842-7727
CITY:	KERMAN	STATE: CA	ZIP CODE:	93630
CAPACITY:	34	CENSUS: 21	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Mory Jaime and Maria Barajas Assistant Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not meeting resident's mobility needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/27/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver the finding for the above allegation. LPA met with Administrator Mory Jaime and Assistant Administrator Maria Barajas and discussed the purpose of the visit.

During the course of the investigation, the Department conducted interviews and records were reviewed.
The department investigated the complaint alleging that staff are not meeting resident's mobility needs. Based on interviews and records reviewed, resident 1(R1) is a hospice resident that requires two person assistance or assistances using the Hoyer lift in which the facility staff was not able to provide.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. Plan of correction was discussed with the Administrator. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator whose signature confirms received of this report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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Control Number 24-AS-20230908170024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AUTUMN RIDGE ASSISTED LIVING	FACILITY NUMBER: 107206271
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2023 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirements – General Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will have staff in-service training on two person assistance and designated staff trained on using Hoyer lift. Training documents with staff rooster of attendance shall be submitted to CCL by 10/20/23.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, the resident is a hospice resident that requires two persons assist or assistance using the Hoyer lift in which the facility did not provided nor trained on the using the Hoyer lift. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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