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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208983
Report Date: 09/20/2021
Date Signed: 09/21/2021 08:35:49 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
06/25/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210625150434
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: 37DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jennifer Fowler - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not give medications to residents correctly.
Facility staff are not properly trained.
Resident eloped from the facility.
Residents are not adequately supervised.
Residents do not receive proper care at the facility.
INVESTIGATION FINDINGS:
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On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA met with Executive Director Jennifer Fowler and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, reviewed records, and conducted facility inspections. During medication audit, LPA observed multiple errors and omissions on the medication administration records for a sample of residents. According to statements by multiple staff members, staff felt that they and other staff had not been adequately trained to complete their job duties and were not confident in their abilities to meet the needs of the residents. Records of training which were provided by the Director of Resident Care showed that staff did not receive proper training in operating the Hoyer lift which was required to care for at least two residents.

On 6/24/2021, Resident 1(R1) eloped from the facility without any staff noticing her absence. R1 was found by a former staff member at a nearby restaurant. Staff members stated that the facility is often understaffed, and they are unable to adequately supervise all residents.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 4
Control Number 24-AS-20210625150434
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: SOMERFORD PLACE-FRESNO
FACILITY NUMBER: 107208983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Executive Director agreed to submit POC to LPA by 10/4/2021.
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Based on records review and interviews, Resident 1(R1) eloped from the facility unobserved on 6/24/2021. Based on records reviewed and observation, facility failed to provide supervision to 1 out of 45 residents, which poses an immediate Health & Safety risk to the residents in care.
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Type A
10/04/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This was not met as evidenced by:
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Executive Director agreed to submit POC to LPA by 10/4/2021.
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Based on records reviewed and observation, facility failed to provide medication for 3 residents, which poses an immediate Health & Safety risk to the residents 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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20210625150434
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: SOMERFORD PLACE-FRESNO
FACILITY NUMBER: 107208983
VISIT DATE: 09/20/2021
NARRATIVE
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During review of facility bathing records, LPA observed and recorded that not all residents had received their regularly scheduled showering. On 7/12/2021 and 8/27/2021, LPA observed Resident 2(R2) to have scratches on both of his lower legs, which were bleeding through his socks. LPA observed drops of blood on the floor and walls of R2's room. Facility staff could not provide records of any treatment being sought for the wounds.

See attached 9099D for citations issued in accordance with California Code of Regulations Title 22. An immediate civil penalty of $500 is assessed. A copy of this report and appeal rights were provided to the Licensee via email. Exit interview conducted.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20210625150434
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: SOMERFORD PLACE-FRESNO
FACILITY NUMBER: 107208983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited
CCR
87464(f)(4)
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87646(f)(4) Basic services shall at a minimum include: Personal assistance and care as needed by the resident…with those activities of daily living such as dressing, eating, bathing…This requirement was not met as evidenced by:
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Based on records reviewed and interviews, facility failed to provide showers and grooming for at least 6 residents, which poses potential Health & Safety risk to the residents 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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4