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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 03/15/2023
Date Signed: 03/15/2023 01:03:43 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
11/14/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221114164307
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: 75DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jennifer VasquezTIME COMPLETED:
12:02 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Administrator, Jennifer Vasquez.

Based on interviews conducted, the facility limited Resident (R1’s) private visitation based on the request of R1’s Power of Attorney (POA). R1’s visitation was permitted only in common areas. A record review revealed that R1’s POA documents do not specifically address authority over visitation. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report and Appeal Rights were discussed and left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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-20221114164307
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: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... shall have all of the following personal rights: (11) To have their visitors,... permitted to visit privately during reasonable hours and without prior notice...
This requirement was not met as evidenced by:
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AD has agreed to provide in-service to Directors and care staff regarding personal rights, specifically visitation. AD will provide proof of in-service via sign in sheet to CCLD by the due date.. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer.

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Licensee did not ensure that R1’s visitors were permitted to visit privately. R1’s visitation was restricted by the facility. R1 was allowed visitation with family in common areas, not during mealtimes.
This poses a potential health, safety or personal rights risk to residents 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) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3