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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157203255
Report Date: 11/19/2025
Date Signed: 11/19/2025 02:44:41 PM

Unsubstantiated


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
09/10/2025 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250910123538
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: DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Pamela Carter TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff did not ensure resident's care needs are being met, resulting in a UTI.
Staff do not ensure that resident is not left on the toilet for an extended about of time.
Staff do not ensure a safe environment for residents in care.
INVESTIGATION FINDINGS:
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On 11/19/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to conduct interviews and gather information. LPA stated purpose of visit and met with House Manager, Pamela Carter.

During the course of the investigation, facility was toured, records reviewed, and interviews conducted. This department had insufficient information regarding the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or disprove that the allegations occurred therefore the allegations are UNSUBSTANTIATED.

No deficiencies issued during this complaint visit .

Exit interview conducted. A copy of this report was provided to House Manager for facility records
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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