107206669-12-19-2023-24-AS-SPIY-CZ5M44-20240103081603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206669
Report Date: 12/19/2023
Date Signed: 12/19/2023 09:43:04 AM

Unsubstantiated

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
08/29/2023 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230829084500

FACILITY NAME:	MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE		FACILITY NUMBER:	107206669
ADMINISTRATOR:	MEDINA, MYSTI & ARMANDO		FACILITY TYPE:	735
ADDRESS:	1354 RAMONA AVE.		TELEPHONE:	(559) 292-4183
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	6	CENSUS: 4	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Mysti (Dailey) Medina		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Facility has pests
Staff are incorrectly dispensing medication to a resident
Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit as well as deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Mysti (Dailey) Medina.

During this visit, LPA toured the facility with AD and conducted record review of R1's file.

The facility uses Clark Pest control for experminator services. Service receipts show that service was paid for in June and August 2023. Per AD, there was evidence of a rodent in the home that entered through a hole in a resident closet, pest control was contacted and the hole repaired. There was no evidence of rodent or pest infestation observed during visits to the facility.

A medication audit was conducted and records reviewed for R1. Facility Medication Administration Records (MARs) were reviewed and noted that medications are provided as ordered.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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Control Number 24-AS-20230829084500

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: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE	FACILITY NUMBER: 107206669
	VISIT DATE: 12/19/2023

NARRATIVE

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Based on interview, staff did not report unexplained injury or concerns related to R1. R1's IPP reveals R1 will throw self or collapse onto the floor. Quarterly reports and facility logs were reviewed which note increased aggressive behavioral episodes. There were no Incident Reports provided. R1 is mostly non-verbal and refused to be interviewed.

Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur.

There were no citations issued

An exit interview was conducted and a copy of this report was signed by AD and emailed to mtsti@medinahomecare.com.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

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