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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209492
Report Date: 04/16/2025
Date Signed: 04/16/2025 04:22:13 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
04/11/2025 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250411152911
FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR:DHALIWAL, KARENFACILITY TYPE:
740
ADDRESS:14280 W STANISLAUS AVETELEPHONE:
(661) 972-4646
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:54CENSUS: 35DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Karen DhaliwalTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not responding to client's calls for assistance in a timely manner
INVESTIGATION FINDINGS:
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On 04/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct initial complaint investigation. LPA introduced self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA delivered complaint findings.

During the course of the investigation, the Department conducted interviews, toured the facility with Administrator and reviewed records. Administrator stated that call pendants are responded to within 10 to 15 minutes. Administrator and LPA observed a sample of residents' call pendant in which were not responded to in a timely manner upon activation.

Based on observation and records reviewed, the preponderance of evidence standard has been met,
therefore, the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D.An exit interview was conducted. A copy of this report and appeals was provided to the Administrator, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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 2
Control Number 24-AS-20250411152911
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: AUTUMN RIDGE ASSISTED LIVING
FACILITY NUMBER: 107209492
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2025
Section Cited
CCR
87411(d)(3)
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87411(d)(3) Personnel Requirements – General All personnel shall be given on the job training…This training and/or related experience shall provide knowledge of and skill…by safe and effective job performance, Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.

This requirement was not met:
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Administrator will have in-service training for all staff regarding answering residents pendant alert call in a timely matter. Documents of staff in-service training and rooster of attendance shall be submitted to Fresno CCL by due date 04/29/25.
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Based on observation and records reviewed, at approximately 01:37PM, LPA and Administrator observed resident call pendant not being responded by staff in a timely matter upon activation. Call log record total average staff responds to residents’ call in one day is above 49.78 minutes from 04/01/25 to 04/16/25, which poses a potential health and safety and personal rights risk to the person in care.
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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: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2