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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208983
Report Date: 07/20/2021
Date Signed: 07/22/2021 11:52:14 AM



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
03/15/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210315114308
FACILITY NAME:SOMERFORD PLACE-FRESNOFACILITY NUMBER:
107208983
ADMINISTRATOR:FOWLER, JENNIFERFACILITY TYPE:
740
ADDRESS:6075 N. MARKSTELEPHONE:
(559) 446-6226
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:64CENSUS: 47DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Jennifer Fowler - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate record keeping
Staff is interfering with a resident's medical care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, Licensing Program Analyst (LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA identified himself and discussed the purpose of the visit with Administrator Jennifer Fowler.

During the course of the investigation, the Department conducted interviews with staff and the responsible party. Records of the incident, the facility’s procedures, and hospice care plan were also reviewed. Based on interviews conducted and records reviewed, the allegations are Unsubstantiated. No deficiency was observed. Exit interview conducted, and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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