107206929-7-21-2021-24-AS-SPIY-C5KLT3-20210804090140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 07/21/2021
Date Signed: 07/21/2021 07:01:35 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
07/19/2021 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210719092518

FACILITY NAME:	PAINTBRUSH ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	107206929
ADMINISTRATOR:	JENNIFER VASQUEZ		FACILITY TYPE:	740
ADDRESS:	4356 W ASHLAN AVE		TELEPHONE:	(559) 275-2000
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	110	CENSUS: 83	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jennifer Vasquez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff does not respond to call buttons in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown conducted the subsequent complaint investigation visit to the facility to obtain additional information. LPA met with Administrator, Jennifer Vasquez. During the course of this visit LPA interviewed facility Administrator and obtained and/or reviewed facility records which include 7/1/21 – 7/21/21 “Pendent Report” for all residents, the July 2021 staff schedule for Assisted Living (AL) and Memory Care (MC) as well as the schedule of “Agency" staffing used.

The Department has investigated the complaint alleging: Staff did not respond to call buttons in a timely manner. Based on the interview and records review of the facility “Pendent Report” dated 7/5/21, it is determined that R1’s call button (or pendent) was activated and not “cleared” by facility staff for 38 minutes resulting in R1 requiring emergency medical care. The preponderance of evidence standard has been met; therefore the allegation has been found to be SUBSTANTIATED.

See attached 9099-D for deficiency
An exit interview has been conducted with Administrator, Jennifer Vasquez. Appeal Rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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-20210719092518

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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care… The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licencee agrees to provide a written statement to CCLD describing the actions in process to adress increased staffing needs, pendent report monitoring and correction action taken with staff. Statement to also include the new staffing plan, effective date(s) and sample schedule for August 2021 to be submitted via email to CCLD by 7/22/2021.
	8 9 10 11 12 13 14	Licensee did not ensure resident call buttons were responded to timely. R1's call button or "pendent" was not cleared for 38 minutes 38 minutes resulting in R1 requiring emergency medical care. This poses an immediate Health and Safety Risk to persons in care.	8 9 10 11 12 13 14	Licencee has agreed to provide RA and LVN training on the facility call button response expectations. A sign in sheet which includes date, description, staff names and signatures will be sumbitted to CCLD by 8/1/21
	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 Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

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