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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209303
Report Date: 01/08/2025
Date Signed: 01/13/2025 03:43:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
10/02/2024 and conducted by Evaluator Martin Vega
COMPLAINT CONTROL NUMBER: 24-AS-20241002160017
FACILITY NAME:PSALMS 23 LOVING CARE RESIDENTIAL IIIFACILITY NUMBER:
107209303
ADMINISTRATOR:COOLEY, I'ISHAFACILITY TYPE:
735
ADDRESS:441 W ALLUVIAL AVETELEPHONE:
(559) 270-3822
CITY:PINEDALESTATE: CAZIP CODE:
93650
CAPACITY:4CENSUS: 2DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator - I'isha CooleyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have Restricted Health condition care plan
Facility does not reporting incidents
Mattress is disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/08/25 at 02:00 PM, Licensing Program Analyst (LPA) M. Vega met with Administrator/licensee I'isha Cooley to conduct an investigation and deliver the findings for the above allegation.
The department received a complaint on 10/02/2024 alleging that, Facility does not have Restricted Health condition care plan, Facility does not reporting incidents and Mattress is disrepair, during the investigation LPA conducted an inspection of the facility, reviewed 1 if 2 resident records and conducted interviews with staff and residents. LPA observed Resident 1 (R1) mattress with stains and a foul odor comming from mattress. Per review of R1 file there was various Incident Reports that had not been faxed.

During the investigation, LPA interviewed Staff 1 (S1) disclosed that R1 did not have a restricted health condition care plan for diabetes per R1 restricted health condition.

Continuation on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
10/02/2024 and conducted by Evaluator Martin Vega
COMPLAINT CONTROL NUMBER: 24-AS-20241002160017

FACILITY NAME:PSALMS 23 LOVING CARE RESIDENTIAL IIIFACILITY NUMBER:
107209303
ADMINISTRATOR:COOLEY, I'ISHAFACILITY TYPE:
735
ADDRESS:441 W ALLUVIAL AVETELEPHONE:
(559) 270-3822
CITY:PINEDALESTATE: CAZIP CODE:
93650
CAPACITY:4CENSUS: 2DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator - Iisha CooleyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained fractures
Facility staff did not seek timely medical attention for resident
Facility staff did not observe resident's change in condition
Facility is not meeting the medical care needs of the resident
Facility does not have adequate food supply
Residents do not have access to food
Facility is malodorous



INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/08/25 at 02:00 PM, Licensing Program Analyst (LPA) M. Vega met with Administrator/licensee I'isha Cooley to deliver the findings for the above allegation.
The department received a complaint on 10/02/2024 alleging that Resident sustained unexplained fractures, Facility staff did not seek timely medical attention for resident, Facility staff did not observe resident's change in condition,

Facility is not meeting the medical care needs of the resident, Facility does not have adequate food supply,
Residents do not have access to food and Facility is malodorous

During the investigation, LPA interviewed Resident 1 (R1) however was not able to clearly communicate with R1, LPA entered facility and facility did not have foul odor. Reviewed record obtained and well.

Continuation on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 5
Control Number 24-AS-20241002160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL III
FACILITY NUMBER: 107209303
VISIT DATE: 01/08/2025
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
Records did not reveal that fractures were unexplained, that facility did not seek timely medical attention for resident, Facility did not observe change in condition, Facility is not meeting the medical care needs of the residents, based on receipts provided by facility, Facility does not have adequate food supply, Residents do not have access to food was not able to corroborate the allegation.

Therefore allegations, Resident sustained unexplained fractures, Facility staff did not seek timely medical attention for resident, Facility staff did not observe resident's change in condition, Facility is not meeting the medical care needs of the resident, Facility does not have adequate food supply, Residents do not have access to food, Facility is malodorous, is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the
alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
An exit interview was conducted where a copy of this report was provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20241002160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL III
FACILITY NUMBER: 107209303
VISIT DATE: 01/08/2025
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
LPA concluded that, Facility does not have restricted health condition care plan for R1 for diabetes, facility was not reporting incidents to CCLD for the time frame of 02/01/24 - 09/30/24. and Mattress is mal odorous and stained, during the investigation. These deficiencies were cited.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division), are being cited on the attached LIC 9099D.

An exit interview was conducted where a copy of this report was provided along with LIC 9099D, LIC 421BG
and Appeal Rights.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 24-AS-20241002160017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL III
FACILITY NUMBER: 107209303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
85088(c)(1)
1
2
3
4
5
6
7
85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client of the following ,... hygiene.(1) An individual bed,... maintained in good repair,..., a clean mattress and pillow(s). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Communicate with CVRC to cover the cost of the mattress up to 500 dollars.
01/15/24.
8
9
10
11
12
13
14
Based on observation, interview, the licensee did not comply with the section cited above in one (1) resident mattress was not clean, mattress has foul odor and stains, which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
01/15/2025
Section Cited
CCR
80092.2(a)(1)-(8)
1
2
3
4
5
6
7
80092.2 Restricted Health Condition Care Plan (a)... specified in Section 80092, the licensee shall develop and maintain,... a written Restricted Health Condition Care Plan. The plan must include all of...: (1)-(8).
Restricted Health Condition Care Plan was not on file at CCLD.
1
2
3
4
5
6
7
Provide a Restricted health Plan by due date of 01/15/25.
Type B
01/15/2025
Section Cited
CCR
80061(b)
1
2
3
4
5
6
7
80061 Reporting Requirements (b) ... specified in (1) below, a report shall be made to the licensing... In addition, a written report containing... (2) below shall be submitted... seven days... occurrence of such event. - Incident Reports were not reported to CCLD during 02/01/24 - 09/30/24
1
2
3
4
5
6
7
Submit all incident reports and provide training to staff about SIR submission and a copy of the SIR submition process to CCLD. by due date of 01/15/25. Provided administrator with CCLD Fax Number as well 559-243-8088.
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: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5