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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208900
Report Date: 07/30/2024
Date Signed: 07/30/2024 10:46:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
05/09/2024 and conducted by Evaluator Jacques Leffall
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240509105631
FACILITY NAME:CALIMYRNA ASSISTED LIVINGFACILITY NUMBER:
107208900
ADMINISTRATOR:PETERS, TYSONFACILITY TYPE:
740
ADDRESS:1545 W CALIMYRNA AVETELEPHONE:
(559) 412-2335
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
07/30/2024
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tyson Peters, Robert McKnight, Carlos Santos
Licensee and Administrators		TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff physically assaulted a resident
INVESTIGATION FINDINGS:
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On this date, Licensing Program Analyst (LPA) J. Leffall and Licensing Program Manager (LPM) S. Moua met with Licensee, Tyson Peters, Licensee, Robert McKnight and Administrator, Carlo Santos. The above allegation was discussed and finding was delivered.

The Department conducted interviews and reviewed records. Based on the records reviewed, S1 slapped R1. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Citation is issued per Title 22 on the attached LIC 9099D. Appeal rights were given and exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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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Control Number 24-AS-20240509105631
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CALIMYRNA ASSISTED LIVING
FACILITY NUMBER: 107208900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities - To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:
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Facility will terminate employee and retrain all staff in the facility on caring for residents.
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Based on the records reviewed, S1 slapped R1, which poses an Immediate Health and Safety risk.
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
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