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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209035
Report Date: 11/17/2021
Date Signed: 11/17/2021 10:12:15 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
10/18/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211018154830
FACILITY NAME:TRUEWOOD BY MERRILL, CLOVISFACILITY NUMBER:
107209035
ADMINISTRATOR:FLAHERTY, TRACYFACILITY TYPE:
740
ADDRESS:675 W ALLUVIAL AVENUETELEPHONE:
(559) 325-8400
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:148CENSUS: 120DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jeremy Salas, Memory Care DirectorTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Resident sustained a fall while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit. Administrator Tracy Flaherty was not present at the time of the visit. LPA spoke with Administrator regarding the findings and designated Jeremy Salas, Memory Care Director to sign this report.

The Department conducted interviews with facility staff, Kaiser Permanente staff and records reviewed. Per interviews, Resident (R1) fell and did not report it to facility staff. Per records reviewed, there were no reported falls in October 2021. LPA was unable to determine what date R1 fell. Per staff interviews and facility assessment records, R1 is independent and did not required assistance with mobility/ambulation. On 10/16/2021, R1 was transported to the hospital due to her medical condition cellulitis, which R1 was being seen by Home Health. Based on interviews and records, R1 was provided immediate evaluation and assistance by the facility staff.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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-20211018154830
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: TRUEWOOD BY MERRILL, CLOVIS
FACILITY NUMBER: 107209035
VISIT DATE: 11/17/2021
NARRATIVE
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Per Kaiser Permanente staff, R1 was admitted due to R1’s medical condition cellulitis and nothing related to a fall. We have found that the complaint was Unfounded, therefore we have dismissed the complaint.
Exit interview was conducted. Memory Care Director was provided with a copy of this report.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2