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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206609
Report Date: 05/10/2021
Date Signed: 05/12/2021 10:36:07 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
02/26/2021 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210226125000
FACILITY NAME:GETTYSBURG CHRISTIAN HOMEFACILITY NUMBER:
107206609
ADMINISTRATOR:DYER, ELIZABETHFACILITY TYPE:
740
ADDRESS:4844 E. GETTYSBURGTELEPHONE:
(559) 294-9080
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:18CENSUS: 12DATE:
05/10/2021
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Licensee, Elizabeth DyerTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Staff did not observe changes in resident's condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced complaint visit, via telephone, due to Covid-19 precautionary measures. LPA Williams spoke with Licensee Elizabeth Dyer and discussed the purpose of the visit; to deliver complaint findings.

LPA Williams conducted staff interviews, resident interviews, facility records reviews, and medical records review.

According to Staff 1 (S1) and Staff 2(S2), Resident 1 (R1) sat in a recliner, which the back of the recliner faced the entrance to the bedroom.

On 2/4/2021, at approximately 5:15 a.m., Staff 2 initially attempted to verbally wake R1 for breakfast with no success.

*Continued on LIC 9099-C*
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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 5
Control Number 24-AS-20210226125000
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: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609
VISIT DATE: 05/10/2021
NARRATIVE
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According to Resident 2 and Resident 3, R1 was normally up to eat breakfast.

S1 conducted a full observation of R1 at 7:10 a.m. Between 7:10 a.m. and 9:50 a.m., S1 checked on R1 two additional times, from the threshold of the bedroom door, which only the back of the recliner and R1’s arm and leg were visible. Each occasion, S1 reported making comments to R1 and not receiving a response.

At 9:50 a.m. S1 observed R1 to be unresponsive and contacted Emergency Medical Services.

Based on interviews and records review the preponderance of the evidence standard has been met,


therefore the above allegation is found to be SUBSTANTIATED. California Code Regulation, Title 22, Division
6, Chapter 8, Section 87466, is being cited on the attached LIC 9099-D.

LPA Williams reviewed LIC 9099-D and plan of correction with the Licensee.

Exit interview was conducted and a copy of this report and appeal rights were provided.

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

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/26/2021 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210226125000

FACILITY NAME:GETTYSBURG CHRISTIAN HOMEFACILITY NUMBER:
107206609
ADMINISTRATOR:DYER, ELIZABETHFACILITY TYPE:
740
ADDRESS:4844 E. GETTYSBURGTELEPHONE:
(559) 294-9080
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:18CENSUS: 12DATE:
05/10/2021
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Licensee, Elizabeth DyerTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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2
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9
Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced complaint visit, via telephone, due to Covid-19 precautionary measures. LPA Williams spoke with Licensee Elizabeth Dyer and discussed the purpose of the visit; to deliver complaint findings.

LPA Williams conducted staff interviews, witness interviews, facility and medical records review.

On 2/4/2021, Staff 1 reported observing Resident 1 unresponsive at approximately 9:50 a.m. and contacting Emergency Medical Services.

According to American Ambulance records, call for service at the facility address was received at 10:08 a.m.

*Continued on LIC 9099-C*
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20210226125000
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: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609
VISIT DATE: 05/10/2021
NARRATIVE
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This agency has investigated the complaint alleging staff did not seek timely medical attention for resident. We have found that the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, we have dismissed the complaint.

Exit interview was conducted with the Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20210226125000
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: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2021
Section Cited
CCR
87466
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87466 Observation of the resident, the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning ...and that appropriate assistance is provided when such observation reveals unmet needs.

This requirement was not met evident by:
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Licensee has agreed to create a daily resident log document, to minotor residents during sleeping hours. Additionally, the Licensee will train staff regarding the new resident log.

Licensee shall submit a letter to the Department by plan of correction due date, 5/11/2021,
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Based on interviews and record reviews, the Licensee did not ensure Resident 1 was regularly observed to monitor for changes in condition, which poses an immediate health and safety risks to persons in care.
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acknowledging the resident log and staff training roster will be submitted to the Department by 5/14/2021 at 4:00 p.m.
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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: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5