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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 08/25/2025
Date Signed: 08/25/2025 06:23:19 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
08/20/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250820163504
FACILITY NAME:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:EDWARDS, DEANNEFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Deanne EdwardsTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff dispensed medication(s) not prescribed to residents
Staff did not report incident involving residents as required
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint visit. LPA explained the reason for the visit and discussed the allegations with Administrator (AD) Deanne Edwards. Investigation findings were delivered to the facility during this visit.

This Department investigated the allegations above. Interviews were conducted and confirm that on 7/21/25, Residents R1 and R2 were given and took the wrong medications. Based on interview and record review of Med Tech chart Notes the incident was not reported to the resident's representatives as required. Additionally, an incident Report was not submitted to CCLD. 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 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 provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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 3
Control Number 24-AS-20250820163504
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed…. (4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by:
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Licensee's contracted consultat provided in person medication re-training for all medication related staff. Proof of training provided during the visit.
DEFICIENCY CLEARED DURING VISIT
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Licensee did not ensure residents were assisted with self-administration of medications as needed. Staff MT gave R1 and R2 the wrong medications on 7/21/25.
This poses an immediate health and safety risk to 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20250820163504
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee... (1) A written report shall be submitted to the licensing agency and to the person responsible...( D) Any incident which threatens the welfare, safety or health of any resident…
This requirement was not met as evidenced by:
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AD has agreed to notify R1 and R2's Responsible Persons and Physicians of the medication errors. Additionally, a written statement which includes the facility Incident Report procedure and that all reporting has been completed will be submitted. to CCLD by poc date.
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Licensee did not ensure a written report was submitted to CCLD for the medication errors which occured 7/21/25. Additionally, the facility did not report the incident to R1 and R2's Responsible Persons or Physicians.
This poses a potential health and safety risk to 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3