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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157202411
Report Date: 10/25/2022
Date Signed: 10/25/2022 01:44:58 PM

Unfounded


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
10/10/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20221010101449
FACILITY NAME:BLUE PEARL HOME CARE IIFACILITY NUMBER:
157202411
ADMINISTRATOR:PINO, JELYNFACILITY TYPE:
740
ADDRESS:10018 SAINT ALBANS AVENUETELEPHONE:
(661) 412-8164
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Petro CrisostomoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident's medical needs are being met.
Staff did not administer resident's medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/25/22, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by caregiver, stated the purpose of the visit and was allowed entry. LPA met with Licensee to discuss findings.

LPA reviewed records and conducted interviews. Based on records reviewed, it was documented by R1's Primary Care Physician that "finger sticks" were discontinued on 09/27/22. Hospice Care plan dated 09/27/22 documented that facility was no longer responsible to take blood sugar readings for R1 now that R1 is receiving Hospice services.

LPA reviewed R1's centrally stored medication records for the month of October and interviewed R1. Records review and interviews verified that medication was received and self administered by R1 daily, after meals, as instructed by PCP.

(Continued on 9099-C)



Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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-20221010101449
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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411
VISIT DATE: 10/25/2022
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
(Continued from 9099)

Based on information received, we have found that the complaint allegations are UNFOUNDED, meaning that the allegations are is false, could not have happened and or is without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted. A copy of this report was provided to Administrator. No deficiencies cited.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2