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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206629
Report Date: 04/07/2022
Date Signed: 04/07/2022 06:37:55 PM

Unfounded


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
03/29/2022 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20220329092627
FACILITY NAME:ELIM PLACEFACILITY NUMBER:
107206629
ADMINISTRATOR:WOLF, RACHEL E.FACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(559) 875-7268
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:44CENSUS: 28DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Assistant Administrator (AA) Maria Ceballos; TIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident unwitnessed fall was the result of lack of care and supervision.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
A complaint visit was conducted on the date & time indicated above by Licensing Program Analyst (LPA) K. Mcclurg met with Assistant Administrator (AA) Maria Ceballos.

Incident reviewed & resident (R1) records reviewed. Incident reviewed with AA. Incident reported to the Department. Facility policy & procedures were followed. R1 did not sustain injury. R1 returned to facility same day.

The Department has investigated the above allegation & determined that it is unfounded.
Unfounded
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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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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