<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208983
Report Date: 09/20/2021
Date Signed: 09/21/2021 08:54:10 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
07/06/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210706163758
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 - Executive DIrectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident suffering multiple falls.
Staff did not provide adequate supervision to resident's.
Facility is not properly managing resident's medication.
Facility is unsanitary.

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 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. Based on reviews of facility incident reports and statements from facility staff, residents in the facility suffered multiple preventable falls due to lack of supervision during June and July 2021. 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. During a medication audit on 8/27/2021, LPA observed multiple errors and omissions on the medication administration records for three residents. Facility staff stated that there have recently been medication errors for multiple residents and residents have missed their medications. During facility inspection, LPA observed the facility to be unsanitary. LPA observed the floors and counters in common areas to have dust and debris. LPA observed drops of blood and dead skin in the bedroom of a resident.
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 5
Control Number 24-AS-20210706163758
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During facility inspection, LPA observed the facility to be unsanitary. LPA observed the floors and counters in common areas to have dust and debris. LPA observed drops of blood and dead skin in the bedroom of a resident. See attached 9099D for citations issued in accordance with California Code of Regulations Title 22. 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: 2 of 5
Control Number 24-AS-20210706163758
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
87465(c)(2)
1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Executive Director agreed to submit POC to LPA by 10/4/2021.
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14
Type A
10/04/2021
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Executive Director agreed to submit POC to LPA by 10/4/2021.
8
9
10
11
12
13
14
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.
8
9
10
11
12
13
14
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: 3 of 5
Control Number 24-AS-20210706163758
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
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation (a):The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Executive Director agreed to submit POC to LPA by 10/4/2021.
8
9
10
11
12
13
14
Based on interviews and observation, the facility failed to keep the clean and sanitary in common areas and at least 1 bedroom, which poses potential Health & Safety risk to the residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 5
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
07/06/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210706163758

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 - Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not report an incident to resident's responsible party.
Staff withheld food from resident.
Facility did not ensure resident's are provided an adequate amount of incontinence care products.
Staff withheld resident's medication.
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 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. Upon review of facility incident reports and internal reporting, it was determined that facility staff reported incidents to residents’ responsible parties. Based off of interviews with staff and review of records, at least one resident regularly refused her meals. If residents refused or slept through a meal, staff package the meal and attempt to feed the resident later. During multiple inspections, LPA observed an adequate supply of incontinence supplies. Facility staff were able to access a central store of additional incontinence supplies when local supplies ran low. The above alleations are unsubstantiated. Exit interview conducted. A copy of the report was provided to the licensee 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: 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: 5 of 5