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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206609
Report Date: 06/01/2021
Date Signed: 06/01/2021 04:22:35 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
05/21/2021 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210521085044
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: 14DATE:
06/01/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee, Elizabeth DyerTIME COMPLETED:
04:17 PM
ALLEGATION(S):
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Facility is not releasing resident records to designated representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Darius Williams conducted a complaint visit to deliver findings. LPA Williams met with Licensee Elizabeth Dyer, and discussed the purpose of the visit.

On 5/25/2021, the Licensee verified receiving written request for Resident 1’s (R1) records from R1’s designated representative (DR) on 5/21/2021. The Licensee did not provide a copy of R1's records to DR.

On 6/1/2021, the Licensee reported mailing R1’s records to the DR on 5/28/2021.

Based on interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87506(c)(1) is being cited on the attached LIC 9099-D.

*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: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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 3
Control Number 24-AS-20210521085044
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: 06/01/2021
NARRATIVE
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LPA Williams discussed the plan of correction with the Licensee.

An exit interview was conducted, 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: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20210521085044
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: 06/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2021
Section Cited
CCR
87506(c)(1)
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87506 Resident records; (c) All information ...shall be confidential; (1) … The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

This requurement was not met evident by:
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Licensee has agreed to provide a copy of Resident 1 records to the designated representative by plan of correction due date 6/4/2021.

Licensee has provided a Fed-Ex tracking number to Community Care Licensing Department (CCLD)
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Based on interview, the Licensee did not ensure Resident 1’s record was made available to Resident 1's designated representative upon written request, which is a potenital personal rights risk to persons in care.
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CCLD will contact designated representative to verify reciept of package.
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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: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3