107208973-6-10-2022-24-AS-SPIY-CFFR9H-20220616124930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208973
Report Date: 06/10/2022
Date Signed: 06/10/2022 02:14:20 PM

Unfounded

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
03/21/2022 and conducted by Evaluator Lady Cabrera

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220321155531

FACILITY NAME:	MILLBROOK SENIOR CAREHOME		FACILITY NUMBER:	107208973
ADMINISTRATOR:	BAUTISTA, ARLENE		FACILITY TYPE:	740
ADDRESS:	6720 N MILLBROOK AVE		TELEPHONE:	(559) 704-6796
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 4	DATE:	06/10/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Elisa Pua, Assistant Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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9

Facility is mismanaging medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Assistant Administrator Elisa Pua. Administrator was unavailable. During this visit LPA delivered investigation findings regarding the above allegation.

The Department has investigated the complaint alleging: Facility is mismanaging medications is UNFOUNDED. LPA interview staff and clients. On 03/22/2022, LPA conducted medication count and crossed reference Resident’s (R1) Centrally Stored Medication and Destruction Record (LIC622) with Assistant Administrator. No medication error was observed. We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Exit interview was conducted. Assistant Administrator was provided a copy of this report.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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
03/21/2022 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20220321155531

FACILITY NAME:	MILLBROOK SENIOR CAREHOME		FACILITY NUMBER:	107208973
ADMINISTRATOR:	BAUTISTA, ARLENE		FACILITY TYPE:	740
ADDRESS:	6720 N MILLBROOK AVE		TELEPHONE:	(559) 704-6796
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 4	DATE:	06/10/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Elisa Pua,Assistant Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not allow resident to call 911.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Assistant Administrator Elisa Pua. Administrator was unavailable.During this visit LPA delivered investigation findings regarding the above allegation.

During the investigation, LPA interviewed staff, client, and reviewed facility records. Per interviews, Resident (R1) has a cell phone and the facility has a phone line assigned to the residents in the living room that they can use at any time. Based on the interviews conducted the above allegation is UNSUBSTANTIATED. Although the allegation 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 allegations are unsubstantiated.

Exit interview was conducted. Assistant Administrator was provided a copy of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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