107208887-12-7-2021-24-AS-SPIY-C9RRNU-20211216121055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208887
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:02:59 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
11/12/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20211112110838

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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Staff are not changing resident timely
Residents sustained pressure injures while in care

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 interviews and resident chart notes, facility staff are changing reisdents timely. Two out of four residents in the facility had pressure injuries. Both residents were on hospice and receiving care for their wounds from a hospice agency. The 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)

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