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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209048
Report Date: 03/05/2025
Date Signed: 03/14/2025 12:00:07 PM

Substantiated


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
02/26/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250226141132
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: 33DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alexis Martin, LVNTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Facility failed to maintain bathroom cleanliness
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a complaint investigation. LPA explained the reason for the visit and the elements of the allegations with Wellness Director Alexis Martin (LVN) as Administrator (AD) Donna Hurley was unavailable at the time of visit.

During this visit, LPA toured the facility with LVN. LPA was provided a resident roster and randomly selected rooms to observe. LPA observed the bathrooms of 12 currently occupied resident rooms and bathrooms. LPA observed multiple restrooms found to be unsanitary as evidenced by unclean toilets, toilet seats needing repair and briefs not being disposed of properly. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.
An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Alexis Martin.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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
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
02/26/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250226141132

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: 33DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alexis Martin, LVNTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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9
Lack of care and supervision resulting in hospitalization
Facility failed to provide pest control resulting in resident room infestation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a complaint investigation. LPA explained the reason for the visit and the elements of the allegations with Wellness Director Alexis Martin (LVN) as Administrator (AD) Donna Hurley was unavailable at the time of visit.

This Department investigated the allegation: Lack of care and supervision resulting in hospitalization. LPA conducted a record review of Resident (R1's) facility file. R1 moved into the facility on 2/14/2025. Interview and record review of chart notes document 911 was called on 2/18/25 for fever and cough. Additional documentation about R1's condition prior to hospitalization is not available for review and a Special Incident Report was not received by the facility.

This Department investigated the allegation: Facility failed to provide pest control resulting in resident room infestation. LPA toured the facility and did not observe roaches or evidence of an infestation. Pest Control service was provided by Valley Wide Pest Control on 2/26/25.
See LIC9099-C for continuation...



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20250226141132
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: 03/05/2025
NARRATIVE
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Continued from LIC9099 - Unsubstantiated report.

The invoice was provided and notes that "General Monthly Service" was provided on this date. The invoice does not note service specific to roaches in resident rooms.

Based on LPA observation, interview and record review 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.

There were no citations issued. An exit interview was conducted and a copy of this report was left with Alexis Martin.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250226141132
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times..... (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement was not met as evidenced by:
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Administrator has agreed to provide inservice to all staff on the maintenance of resident bathroom requirements. A sign in sheet will be provided containing the name and signature of all appropriate staff attending the inservice. LVN ordered new toilet seats during the visit.
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Licensee did not ensure that resident bathrooms are clean, safe, sanitary and in good repair. LPA observed multiple resident toilets that were unsanitary and unclean. 2 toilet seats are broken requiring replacement and a soiled resident brief was found on the floor in a resident bathroom.
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A receipt and written statement that the repairs have been made as well as a receipt copy will be provided. The poc will be submitted to CCL via email by poc date.
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4