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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:36:35 PM

Substantiated


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
01/13/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220113102916
FACILITY NAME:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER VASQUEZFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 87DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Marilyn CouzensTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Staff not notifying resident's Authorized Representative of incident involving resident.
INVESTIGATION FINDINGS:
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13
LPA Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Resident Care Director (RSD) Marilyn Couzens.
During the visit, LPA obtained/reviewed resident and facility files as well as interviewed staff.

Record Review revealed that S1 received verbal counseling due to not following facility reporting procedure to inform resident authorized representative after an incident like a fall or hospitalization has occurred. Based on interview and record review of the facility Employee Counseling Form The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.

A copy of this report including Plan of Correction and Appeal Rights were provided and an exit interview was conducted with the RSD.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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 5
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
01/13/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220113102916

FACILITY NAME:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER VASQUEZFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 87DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Marilyn CouzensTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident fell and sustained a fracture
Multiple residents sustained unexplained injury while in care
Resident cause injury to other residents
Multiple residents experiencing multiple falls in the facility
Staff yell at residents
Staff not responding to residents calls in a timely manner
Staff handles residents in a physically inappropriate manner
Staff not keeping resident’s room free from odor
Staff keeping facility free of pests
Staff did not report suspected abuse of a resident
INVESTIGATION FINDINGS:
1
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5
6
7
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9
10
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12
13
LPA Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Resident Care Director (RSD) Marilyn Couzens.

During the visit, LPA obtained/reviewed resident and facility files as well as interviewed staff.

ALLEGATION 1: Interviews and records revealed that R1 did sustain multiple falls while in care and on 12/9/2021 experienced a fall resulting in a fracture. Based on interviews and records review it was revealed that fall prevention measures were in place in which facility staff followed. When the incident occurred, R1 was located in the common area of the facility. This was a documented fall intervention in place. Records review also reveals that R2’s falls did not cause death.

SEE 9099-C FOR CONTINUATION
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20220113102916
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: 05/17/2022
NARRATIVE
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ALLEGATION 2: Staff interviews revealed that when a change in skin condition or visible injury is observed there is a reporting protocol in place. Based on records review of facility Narrative Charting it was observed that staff have noted resident changes or injury as well as increased monitoring.

ALLEGATION 3: Interviews and records review were conducted which reveal that R3 is resistive and combative with staff who are assisting in resident daily care. Based on interviews and Needs and Service Plan review, it is documented that R3 at times yells at or becomes agitated at other residents. There were no staff that confirmed ever witnessing R3 abuse or cause physical injury to another resident.

ALLEGATION 4: Interviews and records review confirm that residents fall in care. Based on interviews, staff explained the facility fall procedure when a resident is found having fallen. During interview, there were no staff who confirmed or identified specific residents that experience numerous falls without interventions put in place. Records review indicate that Needs and Service Plans note when a resident is at risk of falls, including interventions.

ALLEGATION 5: Interviews of staff members reveal that staff have not been observed yelling at residents. Based on interviews, staff report that there are residents that are hard of hearing and someone could interpret this as yelling. Based on interview of the Memory Care Director (MRD) reveals that staff are educated on Personal Rights, which include approach and how to speak to residents effectively.

ALLEGATION 6: Interviews and record review of facility Narrative Charting reveal that most of the residents in MC do not use a pendant to call for assistance. Based on interviews, residents in MC do not understand or remember how or when to use the pendant correctly. Staff report that increased resident checks, knowing resident habits and behaviors and encouraging residents to be in common areas help ensure that residents receive assistance when needed. It was observed in facility charting notes that increased monitoring is noted after incidents experience a fall, illness or change of condition.

ALLEGATION 7: Interviews and record reviews were conducted and reveal that staff have been educated on how to properly transfer and/or assist a resident up. Based on staff interview, pulling a resident by their arms is not how they are trained. Records review of facility in-service indicates that this education has occurred.

SEE 9099-C FOR CONTINUATION
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220113102916
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: 05/17/2022
NARRATIVE
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ALLEGATION 8: Interviews and record review indicate that there are multiple ways staff can ensure that the resident rooms are free of odor. Based on interviews, there is a House Keeping schedule and assignment for every resident room. A work order can be made to request carpet cleaning and staff have access to cleaning supplies after House Keeping hours. Records review revealed that House Keeping staff maintain and turn in a log that documents that scheduled cleaning has been completed.

ALLEGATION 9: Interviews and records review reveal that the facility receives scheduled monthly and “as needed” Exterminator services. Based on interview of the Environmental Services Director (ESD), the pest control provides service to the exterior and interior of the facility, including the kitchen. Along with the monthly pest control service, daily pest prevention measures are in place in the kitchen as well. Records review confirms that monthly service as well as “as needed” pest control services are conducted.

ALLEGATION 10: Interviews and record review were conducted. Based on Interview, R4 leaves the facility for scheduled dinner with family weekly. Staff interviews reveal that since Covid “shut downs” R4 has experienced a general decline, increased agitation and anxiety due to missing family visits. Staff interviewed believe that R4 is able to communicate if in pain. Multiple staff members were interviewed, and it was not confirmed that an abuse allegation was reported. Directors interviewed denied that a report was provided to them.

Based on interviews and records reviews conducted by The Department, the allegations 1-10 as listed above are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


A copy of this report was provided and an exit interview was conducted with RSD.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20220113102916
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2022
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement was not met as evidenced by:
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Facility RSD has agreed to provide an in-service to Med Techs and Nurses who are responsible for notifying resident authorized representatives when a incident occures. An in-service sign in sheet as well as materials used for education will be provided to LPA by 5/31/22
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The Licensee did not ensure that changes in resident condition (ie; fall or hospitalization) were documented and brought to the attention of the resident's physician and the resident's responsible person as noted on Employee Counseling Form dated 6/15/21 for S1.

This poses a potential risk to persons in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5