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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157201351
Report Date: 10/21/2025
Date Signed: 10/21/2025 07:52:12 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
10/14/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20251014110451
FACILITY NAME:HOLDEN WAY HOMEFACILITY NUMBER:
157201351
ADMINISTRATOR:ROMERO, EDWARDFACILITY TYPE:
735
ADDRESS:2201 HOLDEN WAYTELEPHONE:
(661) 832-3006
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY:6CENSUS: 6DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
04:36 PM
MET WITH:Administrator Edward RomeroTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Facility did not address changes in physical, mental, emotional and social functioning of resident.
Residents personal rights were violated.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) S. Doucette and L. Salazar arrived at the unannounced to conduct a complaint investigation. LPA's were granted entry by Staff Alicia Almond. Staff contacted the Administrator who responded to assist with the visit.

LPA's interviewed staff and clients. LPA's reviewed client and staff records.

Based on interviews and records review, C1 went to the psychiatric hospital 3 times this year. Based on interviews, C1's behaviors have increased and continuted to increase over the past year and facility staff did not do a reassessment for C1.

Based on interviews and photos, C1 had a behavior where all clients had to be removed from the facility due to C1 causing major damage to the facility. Based on interviews, clients do not feel safe in their own home.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 3
Control Number 24-AS-20251014110451
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: HOLDEN WAY HOME
FACILITY NUMBER: 157201351
VISIT DATE: 10/21/2025
NARRATIVE
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Based on interviews, records review and photos, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED


A copy of this report with appeal rights and plans of corrections were provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20251014110451
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: HOLDEN WAY HOME
FACILITY NUMBER: 157201351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2025
Section Cited
CCR
85068.3(a)
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85068.3 Modifications to Needs and Services Plan (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.
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Licensee agrees reassess and schedule a modification for C1's needs and service plan by POC due date 10/22/25
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This requirement was not met as evidenced by: Licensee did not modify C1's needs and service plan after C1 was admitted into a psychiatric hospital, on one or more occassion, which poses an immediate health safety and or personal rights risk to clients in care.
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Type A
10/22/2025
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping,
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Licensee agrees to submit a plan on how clients rights will not be violated by POC due date 10/22/25
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or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by LPA's interviews conducted, photos of damage, and records review stating clients do not feel safe in their own home which poses an immediate health safety and or personal rights risk to clients 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3