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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 05/07/2021
Date Signed: 05/10/2021 01:52:13 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
02/08/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210208122700
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: 80DATE:
05/07/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident’s room is filthy
Staff did not provide basic laundry service
Staff allowed resident to sleep in soiled bedding for extended periods of time
Resident’s room is malodorous

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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: Resident’s room is filthy. The Department reviewed pictures provided by the Reporting party taken of R1’s room on 1/31/21 and 2/6/2021. During an interview, Administrator confirmed a room inspection was conducted per the Reporting Party request to find the room was not clean. Interviews with S1, S2 and S3 state that while the facility was in quarantine due to a Covid-19 outbreak, the House Keeping Services provided were altered but not suspended. Based on the Department's interviews and review of pictures provided by the Reporting Party, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, Title 22, Division 6 Chapter 3 are being cited on the attached LIC. 9099D.

See 9099-C
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: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
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 5
Control Number 24-AS-20210208122700
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: 05/07/2021
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
The Department has investigated the complaint alleging: Staff allowed resident to sleep in soiled bedding for extended periods of time. Based on interviews with the Administrator, S1 and Reporting Party, R1’s mattress was found to be soiled and without mattress cover by the Administrator upon a room inspection (on or around 1/23/21) requested by the Reporting Party. The Reporting Party visited R1 at the facility on 2/6/21 to find the mattress and linens to be soiled again. The Reporting Party provided pictures of the soiled mattress with date stamp of 2/6/21. The Administrator and Reporting Party confirmed that the facility offered to replace the mattress. Based on the Department's interviews, and pictures provided by the Reporting Party, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, Title 22, Division 6 Chapter 3 are being cited on the attached LIC. 9099D.

The Department has investigated the complaint alleging: Staff did not provide basic laundry services. The Department conducted a record review of the facility “Weekly Laundry Check Off Sheets” during the time frame of November 2020 – February 2021. Photos were provided by the Reporting Party that show soiled laundry and piles of laundry in R1’s apartment. During interview with S1, it was explained that the laundry procedures were altered when the facility was in quarantine due to a Covid-19 outbreak. Per S1, during the facility quarantine, there was a system in place for soiled laundry and linen removal from resident apartments. Based on records review, interviews conducted and photos, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, Title 22, Division 6 Chapter 3 are being cited on the attached LIC. 9099D.

The Department has investigated the complaint alleging: Resident’s room is malodorous. Based on interview with the facility Administrator it was confirmed that R1’s bedroom was found to smell of urine during a room inspection (on or around 1/23/21) requested by the Reporting Party. Based on the Department's interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, Title 22, Division 6 Chapter 3 are being cited on the attached LIC. 9099D.

Exit interview conducted with Jennifer Vasquez. Appeal rights provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20210208122700
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: 05/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2021
Section Cited
CCR
87303(a)(1)
1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Inservice was held at the facility in February 2021 to review Care Provider, Laundry and Housekeeping expectations. Sign in sheet from this inservice to be provided to CCLD by 5/17/2021.

8
9
10
11
12
13
14
Licensee did not ensure R1's room was clean and sanitary. R1's room smelled of urine related to use of soiled linens and mattress.

This poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Housekeeping staff on duty each have their own cart.
Additional explaination and materials are provided to new hires in the area of housekeeping and laundry services. A letter will be provided to CCLD to include added services and procedures in place by 5/172021.
Type B
05/17/2021
Section Cited
CCR
87307(3)(C)
1
2
3
4
5
6
7
87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident......if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
A Manager visual room check procedure and check list will be implemented to ensure the over sight of facility management of each resident's room monthly and as needed. This procedure and a copy of the check list will be provided to CCLD by 5/17/2021.
8
9
10
11
12
13
14
Licensee did not ensure adequate laundry service to ensure R1 did not sleep on soiled bed linens or that soiled clothing was removed from the apartment. Licensee did not ensure R1 had a clean mattress.

This poses a potential risk to persons in care.
8
9
10
11
12
13
14
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: 05/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
02/08/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210208122700

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: 80DATE:
05/07/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not meeting resident’s hygiene needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department has investigated the complaint alleging: Staff not meeting resident’s hygiene needs. A record review was conducted of the facility “Needs and Services Plan” updated 6/9/20. R1 was independent in dressing and toileting and needed “reminders only” with grooming. The plan notes that “resident resists assistance" with Activities of Daily Living (ADLs). S5 confirmed R1's level of care with hygiene needs. S5 stated in an interview that in the last few months at the facility R1 became increasingly agitated when care providers attempted to assist with ADLs or hygiene and often refused bathing. R1 would refuse showers and to change clothes daily. S5 states that when R1 would refuse ADL or hygiene assistance, staff would continue to encourage and offer showers daily. Per S1 and S5, R1 would refuse to allow care providers into the apartment and became agitated. Based on records review and interviews conducted we have found that there is no evidence that the facility did not meet R1’s hygiene needs. 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: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 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
02/08/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210208122700

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: 80DATE:
05/07/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
 Resident fell while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department has investigated the complaint alleging: Resident fell while in care. Based on Record review of the facility Narrative Charting notes and R1’s Needs and Service plan. The Department has determined the fall that occured on 1/31/21 is not a violation of Title 22. There is no evidence that the facility did not provide care and supervision or that there was neglect on the part of the facility. We have determined that the complaint was UNFOUNDED, therefore we have dismissed the complaint.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5