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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206929
Report Date: 09/20/2021
Date Signed: 09/20/2021 01:04:23 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
06/16/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210616140736
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: 86DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Staff are mismanaging residents medication
Staff did not provide basic laundry services in a timely manner
Facility is not abiding by residents admissions agreement
INVESTIGATION FINDINGS:
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LPA Katiie Brown arrived to the facility unannounced for a subsequent complaint visit and to deliver the investigation findings to the facility. LPA met with Administrator, Jennifer Vasquez.

During the visit, LPA interviewed Staff (S6) and Staff (S7).

The Department has investigated the complaint alleging: Staff were mismanaging residents medications. A record review of R1’s Physician’s ordered medications and Medication Administration Record (MAR) was completed. Based on staff interviews and record reviews conducted of R1’s ordered medications, MAR and facility medication procedure it is determined that staff mismanaged R1’s medications and medications were not assisted with and given according to Physician’s orders. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED.

See 9099-C for Continuation

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: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 7
Control Number 24-AS-20210616140736
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: 09/20/2021
NARRATIVE
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The Department has investigated the complaint alleging: Staff did not provide basic laundry service in a timely manner. Based on record review of the facility Laundry and House Keeping Log and Admissions Agreement, interview and pictures provided by the Reporting Party it has been determined that the facility did not provide basic laundry service in a timely manner. Documentation shows that scheduled services were provided but that soiled linens and clothing were discovered and not removed timely. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED

The Department has investigated the complaint alleging: Facility is not abiding be residents admissions agreement. Based on interview and review of the Admissions Agreement signed 4/9/2021, it was discovered that a 30 Day reassessment was not conducted for R1. According to the Reporting Party, this reassessment would have determined additional needs and assistance required for R1. The Department confirmed through interview that the reassessment was not conducted as stated in the Admissions Agreement. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED.


Deficiencies were observed and noted on the attached LIC 809D.

A Plan of Correction was developed, an Exit Interview was conducted and a copy of this report including Appeal Rights were provided to the Administrator

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

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
06/16/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210616140736

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: DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
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9
Staff did not adequately observe the residents change in condition
Staff did not meet residents hygiene needs
Residents room is malodorous
INVESTIGATION FINDINGS:
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2
3
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5
6
7
8
9
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13
LPA Katiie Brown arrived to the facility unannounced for a subsequent complaint visit and to deliver the investigation findings to the facility. LPA met with Administrator, Jennifer Vasquez.

The Department has investigated the complaint alleging Staff did not adequately observe the residents change in condition. Based on staff interviews and a record review was conducted of R1’s Physicians Report and Needs & Service Plan there was no documentation discovered regarding a condition as described by the Reporting Party. During staff and Nurse interviews, it was determined that the condition described was the baseline for R1. 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. The allegation is UNSUBSTANCIATED

See 9099 C for continuation
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: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 24-AS-20210616140736
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: 09/20/2021
NARRATIVE
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The Department has investigated the complaint alleging: Staff did not meet residents hygiene needs. Based on staff interview, it was determined that R1 refused assistance with hygiene and bathing much of the time. Record review of R1’s Needs & Service Plan, Physician's Report and Service Plan document that R1 was independent or required standby assist in providing own hygiene tasks. 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. The allegation is UNSUBSTANTIATED

The Department has investigated the complaint alleging: Residents room is malodorous. Based on interviews conducted of other residents, services are provided to eliminate odors upon request. During interview with staff, it was reported that the room sometimes smelled like R1’s pet had soiled carpet or not been taken outside timely. It was reported that the carpet was cleaned upon request. Based of interview with residents and staff members as well as review of facility provided documentation of housekeeping, carpet cleaning and laundry/trash removal the Department is unable to determine if the allegation occurred. 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. The allegation is UNSUBSTANTIATED.

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

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
06/16/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20210616140736

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: DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing resident with water.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Katiie Brown arrived to the facility unannounced for a subsequent complaint visit and to deliver the investigation findings to the facility. LPA met with Administrator, Jennifer Vasquez.



The Department has investigated the complaint alleging: Staff are not providing resident with water. Based on interview of staff and residents who live at the facility, it is determined that water is available at all times in designated areas and upon request. Water is served at mealtimes as well as in the facility café. Staff members have access to bottled water to bring to resident rooms as well. According to R1’s Physician Report and Needs & Service Plan, R1 is able to ask for assistance or request food/drink items independently. It was observed in resident apartments that bottles of water are stored on counter tops or in a refrigerator in their apartments. The Department has investigated the complaint and 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: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 7
Control Number 24-AS-20210616140736
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: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee has agreed to provide a current list of Med Techs and Nurses approved to provide assistance with and pass out medications along with an Inservice Training Plan to be provided to CCL by 5PM 9/21/21.
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Licensee did not ensure that medications were taken as prescribed by the Physician. R1’s MAR confirms multiple instances where staff did not verify that medications were given according to the facility procedure. Staff interviews confirm that “if its not initialed, the medication was not given. MARs reviewed include April, May, June 2021.

This results in an immediate health & safety risk for persons in care.
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Licensee has agreed to provide Staff In Service to the identified staff members as well as a copy of training materials and sign in sheet. Inservice will review medication pass and documentation procedures. In Service and supporting documentation to be provided to CCL 9/28/21.
Type B
09/28/2021
Section Cited
CCR
87307(3)(C)
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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:
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Licensee has agreed to review the Resident Assistant job description with staff members and provide a copy of supporting documents and sign in sheet to in service/review. Documentation to be provided to CCL by 9/28/21.
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This requirement was not met as evidenced by: Licensee did not ensure that the facility provided accomidations & Service to ensure R1's soiled laundry ws removed from the apartment. Photos were provided of soiled clothing and bedding.

This poses a potential health & 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 24-AS-20210616140736
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: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement was not met as evidenced by:
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Licensee has agreed to submit in writing the new procedure and process for timely assessments to CCL by 9/28/21.
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Licensee did not ensure that all applicable terms and conditions set forth in the admission agreement were met. R1 did not receive a 30 day re evaluation/assessment as stated in the Admissions Agreement dates 4/9/21.

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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7