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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 03/04/2021
Date Signed: 03/10/2021 01:54:35 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
07/16/2020 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20200716092945
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: DATE:
03/04/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Jennifer VasquezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
Resident sustained a fall while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Administrator Jennifer Vasquez.

Based on interviews and review of medical records, R1 was not diagnosed with pressure wounds. Records review states per doctor R1 had an allergic reaction, which can be caused for various reasons.

After records review, per SIR on 7-5-20, R1 had an unwitnessed fall, however the facility followed the proper procedures by assessing R1 and calling 911. R1 was transported by ambulance.

This agency has investigated the complaint alleging Resident sustained multiple pressure injuries while in care and Resident sustained a fall while in care. We have found that the complaint is UNFOUNDED, therefore we have dismissed the complaint.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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 2
Control Number 24-AS-20200716092945
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: 03/04/2021
NARRATIVE
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An exit interview was conducted with Administrator Jennifer Vasquez via telephone and a copy of this report was provided to Administrator Jennifer Vasquez via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2