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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 150406456
Report Date: 11/16/2023
Date Signed: 11/16/2023 05:34:25 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
11/15/2023 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231115160013
FACILITY NAME:CENTRE VILLAGEFACILITY NUMBER:
150406456
ADMINISTRATOR:RODRIGUEZ LOPEZ, NORAFACILITY TYPE:
735
ADDRESS:2500 GOSFORD ROADTELEPHONE:
(661) 836-2500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:76CENSUS: 56DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Nora RodriguezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff denied resident food request.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced initial 10 day visit. LPA Williams met with Administrator, Nora Rodriguez and discussed the purpose of the visit.

LPA Williams interviewed the Administrator, Dietician, and conducted record reviews.

Reported dated 10/27/2023, states that Staff 1 cued Resident 1(R1), that they could not have another snack.The Administrator reported they minimize snacks as they are attempting to assist R1 with weight loss based off the plan completed by a Dietician. LPA interviewed the Dietician who reported not being a physician. LPA and the Administrator reviewed resident records and there were no orders from a physician restricting snacks or a special diet identified on the Physicians Report (LIC602).

*Continued on LIC 9099C*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 3
Control Number 24-AS-20231115160013
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: CENTRE VILLAGE
FACILITY NUMBER: 150406456
VISIT DATE: 11/16/2023
NARRATIVE
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The Administrator reported she is going to train staff and reach out to the physician for assistance.

Based on LPA's interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation, facility staff denied resident food request, is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 1, Article 6, Section 80076(a)(4) is being cited on the attached LIC 9099D.

Plan of correction was reviewed with Administrator.

An exit interview was conducted and a copy of this report and Appeal Rights will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20231115160013
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: CENTRE VILLAGE
FACILITY NUMBER: 150406456
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
80076(a)(4)
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( 4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.

This requirement was not met evident by
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Administrator agreed to train staff on the regulation and contact Resident 1's physicians, for further guidance. Administrator will provide training record to the Department by POC due date, 11/17/2023.
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Based on LPA interview and record review, the Licensee did not ensure, snacks were available to 1 of 56 residents, which poses a potential personal rights violation to persons 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: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3