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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206609
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:03:17 PM

Substantiated


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
06/10/2022 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20220610094246
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:
09/19/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator Elizabeth DyerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident’s are unsupervised
Resident’s are not provided activities
Facility is dirty
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette Licensing Program Manager (LPM) Sergiy Pidgirny and conducted an unannounced complaint visit to deliver findings. LPA and LPM met with Administrator Elizabeth Dyer and discussed the purpose of the visit.

The Department has investigated the allegation: Resident’s are unsupervised, Resident’s are not provided activities and Facility is dirty.

On 6/11/22, while at the facility, LPA observed R2, who has a dementia diagnosis to be outside on the sidewalk in the front of the facility near the public street with no staff supervision. On this date census was 13 with one staff on duty.

On 6/11/22, while reviewing records and touring the facility, LPA was unable to obtain or locate activities available to residents in care.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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
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
06/10/2022 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20220610094246

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:
09/19/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Staff Joyce TorresTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff caused injuries to resident
INVESTIGATION FINDINGS:
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9
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12
13
Licensing Program Analyst (LPA) Shawna Doucette and Licensing Program Manager (LPM) Sergiy Pidgirny conducted an unannounced complaint visit to deliver findings. LPA and LPM met with Administrator Elizabeth Dyer and discussed the purpose of the visit.

The Department has investigated the allegation: Staff caused injuries to resident

Based on record review and interviews, R1 was injured while in care in an attempt stop R1 from entering the street. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20220610094246
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: 09/19/2022
NARRATIVE
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On 06/11/22, LPA entered the facility and smelled a strong odor of urine.

Based on the Departments record review and interviews, and observations 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, Sections 87705(b)(2), 87705(7) and 87303(a)(1) is being cited on the attached LIC 9099D.

Civil penalty was issued

An exit interview was conducted, a copy of this report was provided, and appeal rights were provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220610094246
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: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Plan of Correction POC Licensee agrees to hire more staff by POC due date. Licensee will submit LIC 500 by 10/3/22.
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This requirement was not met as evidenced by LPA observing R1 who has a diagnosis of dementia to be out front of the facility on the sidewalk near the public street which poses and immediate health, safety and/or personal rights risk to residents in care.
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Type B
09/20/2022
Section Cited
CCR
87705(7)
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87705 Care of Persons with Dementia (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation.
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Plan of Correction POC Licensee agrees to submit an activities calendar by POC due date 10/3/22.
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This requirement was not met as evidenced by facility not providing activities for residents in care which poses a potential health safety and/or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20220610094246
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: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Plan of Correction POC Licensee agrees to keep facility clean and oderless. LPA cleared POC during visit.
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(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by Licensee did not provide an odorless facility where facility had a strong odor of urine which poses a potential health safety and or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5