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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157203255
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:18:50 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
06/30/2025 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250630120845
FACILITY NAME:MARIPOSA ARFFACILITY NUMBER:
157203255
ADMINISTRATOR:SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:1106 MINTER AVENUETELEPHONE:
(661) 746-4864
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY:4CENSUS: 3DATE:
09/19/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Pamela Carter, House ManagerTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for residents resulting in hospitalization
INVESTIGATION FINDINGS:
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On 09/19/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by House Manager, Pamela Carter.

This department investigated the above allegation, during the investigation, facility was toured, interviews
conducted and records reviewed. Based on information gathered during interviews and incident reports received by department, there was a delay in R1 receiving follow up medical treatment as ordered by physician on 6/18/25. On 6/19/25, R1 had a fall resulting in a head injury, 911 was not called. R1 was transported to ER several hours later by staff for treatment and was hospitalized.

Based on interviews and records review, and per California Code of Regulations, Title 22, Division 6, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited on the attached 9099-D. If not corrected, this poses an immediate risk to the Health Safety and/or personal rights of residents in care. An immediate civil penalty in the amount of $500 is being assessed for care and supervision. Issuance of additional civil penalties, if any, are pending and currently under review.

Exit interview conducted with House Manger, Pamela Carter. A copy of this report and appeal rights were discussed and provided for facility records. A plan of correction developed and reviewed with LPA.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
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-20250630120845
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: MARIPOSA ARF
FACILITY NUMBER: 157203255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2025
Section Cited
CCR
80065(a)
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a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs **This was not met as evidenced by:

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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements for 80065 are met to the Fresno CCL office by the POC due date.
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Based on records review and interviews, there was a delay in R1 receiving follow up medical care for a UTI and a fall resulting in R1's head injury, which is an immediate health and safety risk to clients in care.
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Type A
09/20/2025
Section Cited
CCR
80075(a)
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a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.**This was not met as evidenced by:
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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements for 80075 are met to the Fresno CCL office by the POC due date.
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Based on records review and interviews, there was a delay in R1 receiving follow up medical care for a UTI and a fall resulting in a R1's head injury, which is an immediate health and safety 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2