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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206579
Report Date: 11/05/2021
Date Signed: 11/08/2021 09:28:46 AM



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
07/14/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20210714100341
FACILITY NAME:BLUE PEARL HOME CARE IIIFACILITY NUMBER:
157206579
ADMINISTRATOR:PINO, JELYNFACILITY TYPE:
740
ADDRESS:10414 BICHESTER COURTTELEPHONE:
(661) 412-8079
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Licensee Petro ChrisostomoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is being abused while in care.
Lack of supervision resulting in resident wandering from facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/05/21, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above complaint allegations. LPA was greeted by Licensee, stated purpose of visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of LPA's entry.

During the course of the investigation, LPA interviewed Staff S1, Resident R1, Licensee and reporting party. LPA requested Service call records from Bakersfiled Police Department. Based on the information received, the allegations are UNSUSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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