107208887-12-7-2021-24-AS-SPIY-C9KLYB-20211210081004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208887
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:02:18 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
10/04/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20211004085526

FACILITY NAME:	FIVE STAR ASSISTED LIVING CORP		FACILITY NUMBER:	107208887
ADMINISTRATOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	2573 W. BARSTOW AVE		TELEPHONE:	(559) 283-8543
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 4	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jasmine Oganyan - Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Facility staff were unable to meet resident's care needs

INVESTIGATION FINDINGS:

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13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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 3

Control Number 24-AS-20211004085526

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: FIVE STAR ASSISTED LIVING CORP	FACILITY NUMBER: 107208887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/21/2021 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services: (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident...the facility shall be responsible for meeting the resident's needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to sumit a plan of correction to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the licensee did not ensure facility staff could meet the needs of one out of six residents, which posed a potential health, safety and personal rights risk to 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: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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
10/04/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20211004085526

FACILITY NAME:	FIVE STAR ASSISTED LIVING CORP		FACILITY NUMBER:	107208887
ADMINISTRATOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	2573 W. BARSTOW AVE		TELEPHONE:	(559) 283-8543
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 4	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jasmine Oganyan - Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
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3
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5
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7
8
9

-Facility staff do not follow doctor's orders for resident in care
-Facility staff did not help resident with incontinent needs
-Facility staff placed resident in bed in an unsafe position resulting in decreased oxygen levels
-Facility staff did not provide activities for resident in care
-Facility has faulty equipment

INVESTIGATION FINDINGS:

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On 12/7/2021, Licensee Jasmine Oganyan attended an office meeting at the Fresno Regional Office. LPA delivered complaint findings during the office meeting.

During the course of the investigation, the Department inspected the facility, conducted interviews, and reviewed records. Based off of rcords reviewed and interviews, facility staff did followed doctor's orders for Resident 1 (R1) and helped R1 with incontinent needs. 1 was also visited by a home health care nurse, who stated that she did not observe staff not helping R1 with her incontinent needs. Facility staff and the responsible party did prop R1 up in bed with pillows for at least two days, but facility staff did adjust her and placed her in her wheel chair as needed. Due to R1's diagnosis and condition, her capacity to particiate in planned activities was limited. The facility does provide activities for residents, and staff and Licensee did state that they encouraged and assisted R1 in participating as appropriate. During facility inspection, required equipment and furnishings were observed to be servicable. The above allegations are Unsubstantiated. A copy of the report was provided to the Licensee. Exit interview conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3