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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208983
Report Date: 12/02/2021
Date Signed: 12/03/2021 02:11:29 PM



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
11/04/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20211104161717
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: 29DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Beronica Galindo - Business Office ManagerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Facility did not respond to changes in resident's health.
INVESTIGATION FINDINGS:
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13
On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA met with Beronica Galindo - Business Office Manager and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, reviewed records, and conducted facility inspections. Based off of interview and records reviewed, the facility did appropriately respond changes in the health of Resident 1(R1). R1 did not have any significant changes in her condition that warranted reassessment based off of her diagnosis. The above allegation is 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: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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
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
11/04/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20211104161717

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: 29DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Beronica Galindo - Business Office ManagerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not consistently communicating with responsible party.
Facility gave inconsistent information to the responsible party regarding the resident's health.
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 Linda Houlihan and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, reviewed records, and conducted facility inspections. According to interviews, facility staff did not respond to multiple inquireies from the responsible party of Resident 1(R1). Facility staff provided inconsistent and contradictory information to the responsible party over the telephone. The above allegations are Substantiated. See attached 9099-D for deficiencies cited in accordance with California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided to the licensee via email.
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: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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 3
Control Number 24-AS-20211104161717
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This Requirement was not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above for at least one Resident, which poses a potential health, safety or personal rights risk to persons in care.
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14
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(9)
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5
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7
87468.1 Personal Rights of Residents in All Facilities (a)(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by:
1
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Based on interviews, the licensee did not comply with the section cited above for at least one Resident, which poses a potential health, safety or personal rights risk to persons 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: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3