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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 08/25/2025
Date Signed: 09/05/2025 08:30:07 AM

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
01/08/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250108144027
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: 70DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Deanne EdwardsTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Resident injured while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit. LPA explained the reason for the visit and discussed the allegations with Administrator (AD) Deanne Edwards. Investigation findings were delivered to the facility during this visit.

This Department investigated the allegation: Resident injured while in care. R1’s Service Plan dated 5/31/23 notes R1 is independent in ambulation and does not address falls or fall risk. Record review of Incident Reports, facility Narrative Charting and interviews conducted confirm R1 experienced multiple falls between 12/12/23 - 12/12/24, many requiring hospitalization. R1’s, Service plan was outdated and Physician Report 6/10/24 incomplete. The facility did not have a safety plan or interventions in place for R1. On 12/12/2024, R1 sustained a fall at thet facility resulting in a fracture.

See LIC 9099C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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
01/08/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250108144027

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: 70DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Deanne EdwardsTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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9
Staff left a resident soiled while in care
Resident sustained a bed sore while in care
Facility did not maintain blood sugar level
Staff did not safeguard a resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit. LPA explained the reason for the visit and discussed the allegations with Administrator (AD) Deanne Edwards. Investigation findings were delivered to the facility during this visit.

This Department investigated the allegation: Staff left a resident soiled while in care. R1’s Needs & Service Plan dated 5/31/23 notes, R1 is incontinent and requires total staff assistance with toileting. Interviews confirm that staff followed a toileting plan. Several staff reported that R1 urinated frequently resulting in the need for absorbent pads on furniture and many brief changes. R1 did have wet briefs throughout the day. When discovered, R1 would be taken right away to the bathroom and changed. The facility did not maintain a log of time or frequency of toileting or brief changes.

See LIC 9099C for continuation

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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-20250108144027
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: 08/25/2025
NARRATIVE
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Continued - Unsubstantiated

This Department investigated the allegation: Resident sustained a bed sore while in care. R1 was hospitalized on 12/12 and again on 12/13/25 – on both dates, records indicate assessments conducted with no skin issues. An RN took a photo on 12/14/24 that appears to be a wound or sore. On 1215/24 a wound specialist described R1’s wound as a “full thickness wound”. The cause is unknown, and the specialist did not determine a stage or specific diagnosis provided. It is unable to be determined when the skin issue originated or the cause of the injury.

This Department investigated the allegation: R1 moved into the facility with a known diagnosis of Diabetes per Physician Report dated 10/11/22. The facility did not have Physician Orders to monitor or test R1’s blood sugar. Though the facility did not have orders to test blood sugar, there also were no interventions in place per the current Service Plan dated 5/31/23 to monitor or identify possible changes in condition to Diabetic related conditions or emergencies.

This Department investigated the allegation: Staff do not safeguard a resident's personal belongings. Interviews with Care Staff and Memory Care Director (MCD) confirmed the missing belongings. Interviews confirm searches for these items were conducted, but they were not found. Employee and Family members state that a log of personal belongings was not maintained. Record review reveals that upon admission, LIC621 Client/Resident Personal Property and Valuables was not completed. A blank copy with a line through it was located in R1’s file.

Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is 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 provided.


SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20250108144027
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: 08/25/2025
NARRATIVE
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Continuation of substantiated report

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.
An Immediate Civil Penalty is being assessed for $500 on the attached on the attached LIC421IM.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 24-AS-20250108144027
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/26/2025
Section Cited
CCR
87464(f)(5)
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87464 (f) Basic services shall at a minimum include: (5) Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident.
This requirement was not met as evidenced by:
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AD has agreed to submit a written stattement which will include the facility procedure for fall risk identification and care planning to CCLD by poc date of 8/27/25 10:00am.
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Licensee did not ensure Resident (R1)'s basic services of regular observation of physical and mental change of condition were met. R1 experienced multiple falls. The facility did not update Service plan or put interventions in place to prevent falls or injury. 12/12/24, R1 fell and sustained a fracture. This poses an immediate health and safety 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5