107206929-3-10-2021-24-AS-SPIY-BZ5QTB-20210315122651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 03/04/2021
Date Signed: 03/10/2021 01:55:33 PM

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
07/16/2020 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20200716092945

FACILITY NAME:	PAINTBRUSH ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	107206929
ADMINISTRATOR:	JENNIFER FOWLER		FACILITY TYPE:	740
ADDRESS:	4356 W ASHLAN AVE		TELEPHONE:	(559) 275-2000
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	110	CENSUS:	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Administrator Jennifer Vasquez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff failed to properly conduct a medical assessment for resident
Staff failed to notify authorized representative of incidents regarding a resident
Staff is not meet resident's hygiene needs
Staff failed to have planned activities for resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Administrator Jennifer Vasquez.

Based on interviews and review of records, R1's medical assessments were completed by the facility. Per records review it was discovered that the assessments were not signed by the representative or the resident.

The allegation Staff failed to notify authorized representative of incidents regarding a resident is being investigated on a subsequent complaint filed by complaintant (Complaint Number# 24-AS-20201007153152).

Based on interviews and records review, LPA was not able to determine if the residents hygiene needs were not being met. There is no evidence to prove this allegation occurred.

Facility submitted a calendars showing planned activities however due to Covid 19 restrictions it is unknown if some activities were limited or cancelled.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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-20200716092945

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: PAINTBRUSH ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 107206929
	VISIT DATE: 03/04/2021

NARRATIVE

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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Jennifer Vasquez via telephone and a copy of this report was provided to Administrator Jennifer Vasquez via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

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