107209000-5-10-2021-24-AS-SPIY-C2ZM4M-20210514091659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209000
Report Date: 05/10/2021
Date Signed: 05/10/2021 04:57:02 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
02/25/2021 and conducted by Evaluator See Moua

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210225133244

FACILITY NAME:	LAURITE SENIOR CARE HOME		FACILITY NUMBER:	107209000
ADMINISTRATOR:	DAVIS, MARITA		FACILITY TYPE:	740
ADDRESS:	5478 E LAURITE AVE		TELEPHONE:	(559) 246-1561
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 3	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Marita Davis, Administrator		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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9

Resident sustained multiple fractures while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S. Moua contacted the facility via telephone to deliver findings due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the complaint allegation and finding with Administrator Marita Davis.

The Department interviewed staff, resident, and reviewed records. Based on interviews conducted, resident and staff denied that R1 is abused, neglected, or sustained injuries recently at the facility. R1 stated she did not know where her injuries came from. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. Exit interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See Moua	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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