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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208995
Report Date: 09/30/2021
Date Signed: 10/01/2021 10:04:32 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
02/10/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210210135323
FACILITY NAME:CARMEL VILLAGE AT CLOVISFACILITY NUMBER:
107208995
ADMINISTRATOR:POPE, LINDAFACILITY TYPE:
740
ADDRESS:1650 SHAW AVENUETELEPHONE:
(559) 297-4900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:127CENSUS: DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director, Linda PopeTIME COMPLETED:
03:37 PM
ALLEGATION(S):
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Staff sexually abused a resident while in care.
INVESTIGATION FINDINGS:
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On 09/30/2021 Licensing Program Anlayst (LPA) M. Garza arrived at facility to deliver complaint findings for the above allegation. LPA was screened and allowed entry into the facility. LPA met with Linda Pope and explained reason for visit.

The Department conducted interviews with facility staff, residents, and reviewed records. R1 confirmed S1 pinched resident’s nipple twice while giving R1 a shower. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See citations on the attached LIC. 9099D.

*Immediate Civil Penalty is assessed for care and supervision.

A copy of this report, appeal rights and deficency were emailed due to COVID precautionary measures being taken. A delivered and read receipt serve as confirmation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 2
Control Number 24-AS-20210210135323
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: CARMEL VILLAGE AT CLOVIS
FACILITY NUMBER: 107208995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/01/2021
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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The Administrator states staff was let go from employment. Facility will provide training to staff on resident’s personal rights and abuse. POC will be submitted to the CCL office by the due date of 10/8/21.
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Based on interviews conducted and records reviewed, S1 pinched R1’s nipple twice while giving R1 a shower, which poses an Immediate Health and Safety risk to the resident in care.

*Immediate civil is assessed.*
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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
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