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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208943
Report Date: 06/05/2025
Date Signed: 06/05/2025 02:59:50 PM

Unsubstantiated


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
06/03/2025 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20250603132231
FACILITY NAME:DIGNITY GARDENS HOME IIFACILITY NUMBER:
107208943
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2814 RIALTO AVETELEPHONE:
(559) 515-6189
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator: Camalah KopaczTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/5/25 at 2:30 pm Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegation. LPA met with Administrator Camalah Kopacz.

The Department conducted an interviews with facility staff Administrator and resident. R1 stated likes living at facility and does not have any issues with staff.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued.

Exit interview conducted. A copy of this report was distributed to Adminsitrator which confirms signature of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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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