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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 03/08/2021
Date Signed: 03/09/2021 03:18:17 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
10/07/2020 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20201007153152
FACILITY NAME:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER FOWLERFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 83DATE:
03/08/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Jennifer VasquezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not coordinating resident's medical care with the resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown contacted the facility via telephone to commence a complaint investigation due to COVID-19 and pre-cautionary measures.

The Department has investigated the complaint alleging: The facility is not coordinating resident's medical care with the resident's authorized representative. Based on interviews conducted and record review of R1’s file, “Narrative Charting” documentation, emails, text messages and phone calls it has been determined that there is no evidence to prove that the facility is not coordinating R1’s medical care with the authorized representative. The allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

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: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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 4
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
10/07/2020 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20201007153152

FACILITY NAME:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER FOWLERFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 83DATE:
03/08/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Jennifer VasquezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility staff did not notify the resident's authorized representative of a change in the resident's condition

Facility staff did not dispense resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown contacted the facility via telephone to deliver the investigation findings due to COVID-19 and pre-cautionary measures.

The Department has investigated the complaint alleging: Facility staff did not notify the resident's Authorized Representative of a change in the resident's condition. Based on interview conducted with R1’s Authorized Representative, records review of the facility “Narrative Charting” documentation and R1’s file, it was determined that staff did not notify the Authorized Representative that Home Health services had been ordered by R1’s Physician and Home Health services were started without the knowledge or authorization of the Authorized Representative. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED. This allegation was addressed on a subsequent complaint (COMPLAINT CONTROL NUMBER: 24-AS-20200716092945).

See 9099-C for continuation
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: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
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 4
Control Number 24-AS-20201007153152
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: 03/08/2021
NARRATIVE
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The Department has investigated the complaint alleging: Facility staff did not dispense resident's medication as prescribed. Based on interview in which S2 confirmed that once a Med Tech has assisted the resident to take their medication, the Med Tech then documents on the Medication Administration Record (MAR) to confirm the medication was given and taken. R1’s MAR was reviewed and it was found that a Med Tech did not initial that a medication was given as ordered on 7/22/21 (AM dose), 7/31/20 (AM and PM doses), 8/13/20-8/15/20 and 8/18/20-8/19/20. Based on interview of staff, review of the facility procedure and R1's MAR it is determined that the medication was not given. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED.


See attached 9099-D for deficiencies cited
An exit interview has been conducted with Administrator, Jennifer Vasquez. Appeal Rights have been provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20201007153152
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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee will provide a written statement to CCL on 3/10/20 stating that training will be provided to all employees that participate in resident medication procedures which includes documentation that a medication was taken as ordered.
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There is no documentation on the Medication Administration Record (MAR) that a medication was given to R1 as ordered

This poses an immediate health and safety risk to persons in care.

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The training will will address the facilities documentation procedure on both electronic and handwritten MARs.
A sign in sheet will be provided to CCL with names and signatures of attendees by 3/16/20.
Type B
03/15/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.

This requirement was not met as evidenced by:
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A training will be provided to all employees who are responsible to communicate activities related to resident care or services to Authorized Represetatives.
A sign in sheet will be provided to CCL with names and signatures of attendees by 3/16/20.
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The licensee did not notify R1's Authorized Representative that Home Health was ordered by the Physician. Home Health services were started without the knowledge or authorization of the Authorized Representative.

This poses a potential health and safety risk to the 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: 03/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4