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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208889
Report Date: 01/10/2024
Date Signed: 02/08/2024 06:25:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
11/09/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20231109141012
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: 5DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility caregiver, Bienvel YapTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegation listed above. LPA met with Facility caregiver, Bienvel Yap , and explained the purpose of today's visit.
Regarding the allegation Resident sustained unexplained injuries while in care. Facility staff reported incidents on 08/09/23, and 08/11/23 documenting Resident 1 did have behaviors while attending day program that could result in unexplained injuries. LPA interviewed two facility staff members who both stated Resident 1 does on occasion have behaviors at the facility that could result in possible injuries such as bruising or scratches . Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time.
No deficincies cited today Per Title 22 Regulations.
Exit interview conducted with facility Facility caregiver, Bienvel Yap, and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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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