<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208889
Report Date: 08/15/2022
Date Signed: 08/15/2022 04:06:05 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
07/14/2022 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20220714142748
FACILITY NAME:LAVERNE SENIOR CAREHOMEFACILITY NUMBER:
107208889
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:3194 LAVERNE AVETELEPHONE:
(559) 292-0074
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
08/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator Elisa Pua, Caregiver Rufinita “Net” Deocampo and caregiver Bienvel "Ben" Yep TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/15/2022, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint inspection and deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Rufinita “Neth” Deocampo and caregiver Bienvel "Ben" Yep. Administrator Arlene Bautista was called and Assistant Administrator Elisa Pua arrived shortly.

During the course of the investigation, LPA reviewed records and interviews were conducted which confirmed staff are not meeting resident’s needs upon request, specifically relating to assisting resident out of bed.

Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights was provided to Assistant Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
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 2
Control Number 24-AS-20220714142748
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: LAVERNE SENIOR CAREHOME
FACILITY NUMBER: 107208889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited
CCR
87411(d)(3)
1
2
3
4
5
6
7
Personnel Requirements – General All personnel shall be given on the job training… This training and/or related experience shall provide knowledge of and skill…by safe and effective job performance, Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

This requirement was not met:
1
2
3
4
5
6
7
Licensee shall have in-service training for staffs regarding meeting residents’ need. Documents of staff in-service training including rooster of attendance shall be submitted to CCL by due date.
8
9
10
11
12
13
14
Based on interviews conducted, on three occasions, staff did not meet R1’s need when requested to be taken out of bed which poses a potential health and safety and personal rights risk to the person in care.
8
9
10
11
12
13
14
Licensee will submit a plan of correction detailing the steps that will be taken to ensure the regulations will be met in the future to Fresno CCL by the due date.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2