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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208918
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:49:18 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
09/24/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210924105830
FACILITY NAME:HARVEST AT FOWLER, THEFACILITY NUMBER:
107208918
ADMINISTRATOR:ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:36CENSUS: 18DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Alex ZaninTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident was hospitalized for cellulitis/sepsis.
Resident did not receive her medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation and deliver findings. LPA took COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Alex Zanin.

Based on medical records review, Resident was hospitalized for cellulitis/sepsis.

Based on records review and interviews, Resident did not receive her medication.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D.
Plan of correction and appeal rights was reviewed with Licensee.

An exit interview was conducted and a copy of this report was provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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 5
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
09/24/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210924105830

FACILITY NAME:HARVEST AT FOWLER, THEFACILITY NUMBER:
107208918
ADMINISTRATOR:ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:36CENSUS: 18DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Alex ZaninTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Resident bathroom in disrepair.
Carpet has an odor.
List of medications was not updated.
Care plan was not updated.
Staff were not aware of the resident's dentures.
Caregiver was providing care for her child instead of the resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA took COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Alex Zanin.

Based on observation and interviews the allegation Resident bathroom is in disrepair is unable to be determined whether or not it was in disrepair at the time. LPA observed the bathroom to be in good condition and working properly.

Based on observation, LPA toured the facility and did not smell an odor in the carpet.

Based on records review, LPA was not able to determine if the medications were updated. Facility did not recieve clear instructions regarding the medication change and contacted the physician for clarification. Facility obtained the clarification later that same day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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 5
Control Number 24-AS-20210924105830
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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918
VISIT DATE: 12/15/2021
NARRATIVE
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Based on interviews and records review, facility completed a supplemental report to the original care plan for R1 once she returned from the hospital.

Based on interviews, staff was aware of R1's dentures.

Based on interviews, staff did bring a child to work to visit with the residents however it is unknown if the residents were or were not being cared for during the time.

Although the facility temporarily had a change in staffing and did not have an activities director for a duration of about a month the facility was providing activities based on interviews and activities calendar. Facility currently has a new activities director.

Although the allegations Resident bathroom in disrepair, Carpet has an odor, List of medications was not updated, Care plan was not updated, Staff were not aware of the resident's dentures and Caregiver was providing care for her child instead of the resident may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/24/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210924105830

FACILITY NAME:HARVEST AT FOWLER, THEFACILITY NUMBER:
107208918
ADMINISTRATOR:ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:36CENSUS: 18DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Alex ZaninTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident has an infected pressure injury requiring hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation and deliver findings. LPA took COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Alex Zanin.

The Department has investigated the allegation Resident has an infected pressure injury requiring hospitalization.

Based on records review of R1’s medical records and interviews, it was determined that R1 did not have a pressure wound. We have determined that the complaint was UNFOUNDED, therefore we have dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20210924105830
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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or
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Plan of Correction POC Licensee agrees to provide training to staff on this regulation and submit agenda and signed training by POC due date.
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deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by Based on medical records review, R1 was admitted for cellulitis/sepsis, which poses an immediate Health, Safety or personal rights risk to the clients in care.
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Type A
01/07/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

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Plan of Correction POC Licensee agrees to provide medication training for staff and submit agenda and staff sign in sheet by POC due date.
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(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on review of records and interviews R1 did not recieve the correct dose of medication which poses an immediate Health, Safety or personal rights risk to the clients in care.

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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5