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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206669
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:25:28 PM

Unsubstantiated


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
07/25/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220725085334
FACILITY NAME:MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCEFACILITY NUMBER:
107206669
ADMINISTRATOR:MEDINA, MYSTI & ARMANDOFACILITY TYPE:
735
ADDRESS:1354 RAMONA AVE.TELEPHONE:
(559) 292-4183
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 4DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
03:57 PM
MET WITH:Administrator, Mysti MedinaTIME COMPLETED:
04:36 PM
ALLEGATION(S):
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Kitchen is dirty
Staff do not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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On 12/16/2023 Licensing Program Analyst (LPA) NM. Garza arrived at facility to deliver findings on the above allegations. Administrator was contacted and arrived a short time later. LPA met with Administrator, Mysti Medina and explained reason for visit. LPA was permitted entry into the facility but was not COVID prescreened. A Health and Safety check was completed on residents in care. Residents observed in common areas and in rooms.

During the investigation documents were requested and reviewed and interviews were completed.

Allegation: Kitchen is dirty
During visit on7/27/2022, LPA observation in kitchen showed it to be picked up and staff washing dishes. No food or sanitary issues observed.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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 2
Control Number 24-AS-20220725085334
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: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE
FACILITY NUMBER: 107206669
VISIT DATE: 12/16/2022
NARRATIVE
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Allegation: Staff do not seek timely medical attention for resident
During investigation LPA requested physicians report, current IPP and completed interviews. IPP showed R1 to have behaviors causing R1 to state “their stomach was hurting” and vomiting. Interview with Administrator disclosed this is a “frequent behavior” of R1 and that “if and when R1 needs medical attention they get it for them”.

Although the allegations may or may not have occurred, they do not meet the preponderance of evidence standard. The allegations listed above are UNSUBSTANTIATED.

An exit interview with Administrator, Mysti Medina was completed. A copy of this report was provided. No deficiencies cited during todays visit.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2