<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209048
Report Date: 10/24/2022
Date Signed: 10/24/2022 01:05:03 PM

Unsubstantiated


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
07/08/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220708092450
FACILITY NAME:RIVER BLUFFS MEMORY CARE COMMUNITYFACILITY NUMBER:
107209048
ADMINISTRATOR:HURLEY, DONNAFACILITY TYPE:
740
ADDRESS:5425 W. SPRUCE AVE.TELEPHONE:
(559) 840-9347
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:36CENSUS: 36DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Alexis MartinTIME COMPLETED:
01:29 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair
Staff left resident in soiled clothing for an extended period of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint investigation. Investigation findings were delivered during this visit. LPA met with and explained the purpose of the visit with Wellness Director (WD), Alexis Martin.

During the visit, LPA toured resident rooms, conducted staff interviews and reviewed resident files.
During the initial complaint visit 7/13/22, LPA observed a bubble in the ceiling of room 2 related to a roof leak as described by Administrator (AD). AD submitted invoices from flooring and roof repair companies dated 12/22/21. Based on observations and interviews, LPA was unable to confirm the date of the roof leak. During a facility tour, LPA observed room air conditioning units that were in process of repair. Fans were observed in these residents rooms. Based on observations, record review and interviews conducted, The Department was unable to determine if the facility was in disrepair.

SEE LIC9099-C FOR CONTINUATION OF THIS REPORT
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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 4
Control Number 24-AS-20220708092450
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: RIVER BLUFFS MEMORY CARE COMMUNITY
FACILITY NUMBER: 107209048
VISIT DATE: 10/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on record review of R5's facility file and staff interviews conducted, The Department is unable to determine if Staff left resident in soiled clothing for an extended period of time. Based on interviews and record review of R5's Master Assessment dated 6/8/22 and staff interviews, R5 becomes agitated and very combative if not wanting to be assisted to change after an episode of incontinence. Staff report that depending on R5's mood it may take a long time for R5 to agree to be assisted. R5's skin is intact according to Master Assessment and facility Progress Notes May and June 2022.

Based on LPA observations, records reviews and interviews conducted, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No citations were issued for these allegations

An exit interview was conducted, and a copy of this report was left with Alexis Martin, whose signature on this form confirm receipt of these documents.


SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4