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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206629
Report Date: 03/23/2023
Date Signed: 03/23/2023 05:11:50 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
01/25/2023 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20230125111028
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: 30DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Adminisrator, Maria CeballosTIME COMPLETED:
03:16 PM
ALLEGATION(S):
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Facility is not meeting residents hygiene needs
INVESTIGATION FINDINGS:
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On 3/23/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver complaint findings. LPA met with Administrator, Maria Ceballos. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During the investigation interviews were completed with staff, documentation was requested and reviewed. Based on interviews completed, documentation reviewed and LPA observations R1’s hygiene needs are not being met. The above allegation is found to meet the departments preponderance of evidence standard per Title 22 and is found to be SUBSTANTIATED. Deficiencies cited on LIC 9099D.

Exit interview completed with Administrator, Maria. A copy of this report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 2
Control Number 24-AS-20230125111028
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: ELIM PLACE
FACILITY NUMBER: 107206629
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Per Administrator in-service training was completed on 2/10/23. Administrator to provide training material and in-service sign in sheet to CCL by POC date.
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The following was not met as evidence by: LPA observation, interviews completed with staff and records reviewed showing R1's hygiene needs were not met. Shower records indicated R1 was not showering regularly. Clothing was observed in need of washing and torn and interviews with staff indicated they were not able to assist R1 with hygiene needs due to R1 being combative.
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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: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
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