107209007-8-9-2023-24-AS-SMOA-CZDSSG-20240111130754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209007
Report Date: 08/09/2023
Date Signed: 08/09/2023 05:32:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
08/08/2023 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20230808160621

FACILITY NAME:	FIVE STAR ASSISTED LIVING		FACILITY NUMBER:	107209007
ADMINISTRATOR:	OGANYAN, HASMIK JASMINE		FACILITY TYPE:	740
ADDRESS:	5727 N. HAZEL AVE		TELEPHONE:	(818) 261-4887
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 6	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	02:11 PM
MET WITH:	Licensee, Jasmin Oganyan		TIME COMPLETED:	05:43 PM

ALLEGATION(S):

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Illegal Eviction
Facility accepted a resident who requires a higher level of care

INVESTIGATION FINDINGS:

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, On 8/9/23 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced inital 10-complaint visit. LPA met with Direct Care Staff, Marryan Castillo. Licensee, Jasmin Oganyan was contacted and arrived a short time laterLPA explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents obvserved in common area and in bedrooms.

Allegation: Facility accepted a resident who requires a higher level of care.
During complaint visit LPA completed interviews, reviewed hospice care plan, eviction notice, needs and assessment, admission agreement, home health records. Adminission agreement shows resident moved into the facility 2/18/22. At this time, R1 had a g-tube in place but was not being utilized. R1 was on hospice at the time of admission. Hospice records indicated services ceased on 3/2/23. At this time, R1 required a higher level of care but was not re-assessed. This allegation is SUBSTANTIATED.

CONT...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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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Control Number 24-AS-20230808160621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: FIVE STAR ASSISTED LIVING	FACILITY NUMBER: 107209007
	VISIT DATE: 08/09/2023

NARRATIVE

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CONT...

Allegation: Illegal Eviction.
During visit LPA reviewed documentation provided to responsible party of R1. It was observed that the eviction notice was not completed correctly. Licensee failed to include required verbiage and submit to CCL for approval. This allegation is SUBSTANTIATED.

The above listed allegations were found to be SUBSTANTIATED. Deficiencies cited per Title 22 on LIC 9099D.

Exit interview completed with Licensee, Jasmin Oganyan. A copy of this report and appeal rights given.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230808160621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: FIVE STAR ASSISTED LIVING	FACILITY NUMBER: 107209007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/18/2023 Section Cited HSC 1569.683	1 2 3 4 5 6 7	1569.683 Eviction notices; reasons for eviction contents; service (a)...reasons relied upon for the eviction, with specific facts...(2) Resources available to assist in identifying alternative housing and care options...(3) Information about the resident's right to file a complaint...(4)...statement: "In order to evict a resident..." (b)...serving a 30-day notice...shall notify, or mail a copy of the notice to quit to, the resident's responsible person.	1 2 3 4 5 6 7	Licensee will amend Notice of Eviction to R1 including all required information. The amended notice shall include the date of notice and amended eviction date to allow 30 days from date of amended notice. Health and Safety Code and required language was printed and provided.
	8 9 10 11 12 13 14	This requirement was not met as evidence by"LPA observation of the eviction notice submitted to R1 and responsible party. Eviction notice was not completed correctly. Licensee failed to include required verbiage and submit to CCL for approval. This poses a potential health, safety and or personal rights risk to resident in care.	8 9 10 11 12 13 14
Type B 08/18/2023 Section Cited CCR 87615(a)(2)	1 2 3 4 5 6 7	(a) Persons ...a health condition including...shall not be admitted or retained in a residential care facility for the elderly:(2) Gastrostomy tubes.	1 2 3 4 5 6 7	Licensee to reassess R1 and provided updated documentation to CCL. All staff to complete training on regulations for prohibited health conditions, restricted health conditions and acceptance and retention. Licensee to provide training material and in-service sign in sheet to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: LPA observation of R1 medical records, need and assessment and hopice care plan. R1 requires a higher level of care and no re-appraisal was completed. This poses a potential health, safety and or personal rights risk to resident 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: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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