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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208943
Report Date: 05/24/2022
Date Signed: 05/24/2022 05:11:50 PM

Unsubstantiated


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
03/02/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220302163115
FACILITY NAME:DIGNITY GARDENS HOME IIFACILITY NUMBER:
107208943
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2814 RIALTO AVETELEPHONE:
(559) 917-0440
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
04:56 PM
MET WITH:Licensee Camalah KopoczTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was confined to their bed while in care.
Residents are being confined to their rooms while in care.
Resident's diapering needs not being met.
Resident is not fed food according to their dietary plan.
Resident is being yelled at while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/24/22 Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Licensee Camalah Kopocz.

During the course of the investigation, interviews were conducted, and records were reviewed. It could not be proven or disproven that resident was confined to their bed while in care, that residents are being confined to their rooms while in care, resident’s diapering needs are not being met, residents are not fed food according to their dietary plan and being yelled at while in care. Interviews conducted with staff and resident, R1 confirmed resident are not being yelled while in care, have not been confined to their bed and have not been confined to their rooms while in care. Staff and resident stated residents are being fed with food according to their dietary plan.

Based on interviews and records review, the allegations above is founded to be UNSUBSTATIATED meaning there is not a preponderance of evidence to prove or disprove the alleged violations occurred. No deficiencies issued. An exit interview was conducted. A copy of this report was provided to the Licensee.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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
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
03/02/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220302163115

FACILITY NAME:DIGNITY GARDENS HOME IIFACILITY NUMBER:
107208943
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2814 RIALTO AVETELEPHONE:
(559) 917-0440
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
04:56 PM
MET WITH:Licensee Camalah KopoczTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents are not being administered their medications according to physician's instructions.
Untrained staff.
Medication records are not accurate.
Licensing information is not accessible to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/24/22 Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Licensee Camalah Kopocz.

During the course of the investigation, facility was toured, interviews were conducted, and records were reviewed. Base on medication records reviewed, resident’s medication is administered according to physician’s instruction and recorded accurately by staff. Training records were reviewed staff were trained. Based on observation, Licensing information are accessible to residents in care in the facility.

Based on observation, records reviewed, and interviews conducted, the allegations above is UNFOUNDED, meaning they were false, could not have happened, and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was provided to the Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 2