107208835-4-28-2021-24-AS-SPIY-C2VL6Y-20210510082932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208835
Report Date: 04/28/2021
Date Signed: 04/28/2021 04:35:52 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
09/18/2020 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200918130917

FACILITY NAME:	CREST POINTE ASSISTED LIVING-PRESCOTT		FACILITY NUMBER:	107208835
ADMINISTRATOR:	KEENE, ALICIA		FACILITY TYPE:	740
ADDRESS:	2855 PRESCOTT AVENUE		TELEPHONE:	(559) 765-4321
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93619
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Alicia Keene		TIME COMPLETED:	04:52 PM

ALLEGATION(S):

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8
9

Resdent, R1 fell and was injured when facility chair broke.

INVESTIGATION FINDINGS:

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5
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13

Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this inspection by phone. On this date Licensing Program Analyst (LPA) L. Xiong conducted a Complaint tele-visit to deliver investigation findings regarding the above allegation with Administrator Alicia Keene.
During the course of the investigation, the Department interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Resdent, R1 fell and was injured when facility chair broke. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

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-20200918130917

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: CREST POINTE ASSISTED LIVING-PRESCOTT	FACILITY NUMBER: 107208835
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/05/2021 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	87307(d)(2) Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.	1 2 3 4 5 6 7	Per Administrator, stated after the incident, the rest of the chairs were inspected for safe use and new chairs were purchased to replace all chairs. Administrator will submit receipts/purchase invoice to Community Care Licensing by May 5, 2021.
	8 9 10 11 12 13 14	This evidence was not met as evidence by: The facility failed to take action to protect R1 resulting R1 fell and injured when facility chair broke. **This presents a potential risk to the health and safety of the persons in care.	8 9 10 11 12 13 14
	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: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
09/18/2020 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200918130917

FACILITY NAME:	CREST POINTE ASSISTED LIVING-PRESCOTT		FACILITY NUMBER:	107208835
ADMINISTRATOR:	KEENE, ALICIA		FACILITY TYPE:	740
ADDRESS:	2855 PRESCOTT AVENUE		TELEPHONE:	(559) 765-4321
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93619
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Alicia Keene		TIME COMPLETED:	04:52 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not obtain medical care to resident in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this inspection by phone. On this date Licensing Program Analyst (LPA) L. Xiong conducted a complaint tele-visit to deliver investigation findings regarding the above allegation with Administrator, Alicia Keene.

During this investigation, the Department interviewed staff on duty and obtained and/or reviewed facility records relevant to the complaint investigation. It was determined that the above allegation: Staff did not obtain medical care to resident in a timely manner. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3