<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 02/10/2025
Date Signed: 02/10/2025 04:24:41 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
11/01/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241101112523
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: 66DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Deanne EdwardsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanagaing resident's medication
Staff are not providing resident's authorized representatives with resident's records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Deanne Edwards and explained the reason for the visit.

This Department investigated the allegation: Staff are mismanagaing resident's medication. Based on record review of Narrative Charting Notes, for Resident (R1) February - October 2024, there were multiple instances where the facility ran of of medications Xanax and Memantine resulting in R1 missing medication doses. R1's controlled Drug Medication Administration Record (count) is missing Med Tech documentation that the medication was given as ordered on multiple occasions between 6/1 - 8/17/24. On 7/30/24 and 8/2/24 the count documents medication was given 4 times in a day instead of the ordered 3 per day. The count and MAR show that Xanax was not given from 7/10-7/17/24 due to "miscommunication" as stated on a fax to Physician on 8/12/24. Additionally, Interviews revealed that a medication error occurred due to a staff member giving R1 the wrong medication.

See LIC9099C for continuation of this report
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: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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 4
Control Number 24-AS-20241101112523
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: 02/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This Department investigated the allegation: Staff are not providing resident's authorized representatives with resident's records. Record review of email correspondence confirm that the facility Administrator (AD) declined to provide R1's Durable Power Of Attorney/Responsible Party (DPOA) with copies of R1's MAR as requested. Per DPOA, the MAR has been provided for review in the past with no issues. The current AD informed DPOA "it is our company policy not to release MAR documents at any time". During interview with AD, AD stated that the MAR reports are used as an internal document and not considered part of the resident file/record.

Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance with California Code of Regulations Sections Incidental Medical and Dental Care and Resident Records on the attached LIC 9099-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20241101112523
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: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.... (4) The licensee shall assist residents with self-administered medications as needed.
This requirement ws not met as evidenced by:
1
2
3
4
5
6
7
AD has agreed to submit a written statement to include the immediate actions taken by the facility once the errors were identified. This statement will be submitted via email to CCL by poc date.
8
9
10
11
12
13
14
Licensee did not ensure R1 received assistance with self-administered medications Facility ran out of medications on multiple occasions. A MT gave R1 medications out of the discontinue med storage to avoid having to speak to RP, Xanex was not given due to "miscommunication" 7/10-7/17/24. This poses an immediate health & safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20241101112523
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: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2025
Section Cited
CCR
87506(c)(1)
1
2
3
4
5
6
7
87506 Resident Records (c) All information and records... (1) The licensee shall… The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
AD has agreed to contact R1's Designated Representative to offer to provide the MAR documentation requested. AD will submit a written statement which notes the outcome of the conversation and action taken by the facility to comply with the request. Statement will be submitted by poc date.
8
9
10
11
12
13
14
Licensee did not ensure that confidential information was provided to R1's designated representative when requested. R1's MAR documentation was not provided to R1's DPOA/designated representative upon written request.
This poses a potential health & safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4