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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 09:00:17 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
07/09/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210709101311
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):
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Resident(s) sustained pressure injuries while in care
Facility staff are not providing necessary medication for residents
Facility staff are not meeting resident's hygiene needs
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 three residents. Upon review of facility bathing record, LPA observed that not all residents were receiving their agreed upon schedule of showers and hygiene care. Multiple staff members stated that residents miss their showers due to insufficient staffing. Since June 2021, multiple residents at the facility have sustained pressure injuries of various degrees and sizes. Staff members have stated that residents are not being properly cared for and turned in their beds due to lack of communication and insufficient staffing. 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.
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 3
Control Number 24-AS-20210709101311
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)
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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 3
Control Number 24-AS-20210709101311
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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Executive Director agreed to submit POC to LPA by 10/4/2021.
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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: 3 of 3