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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206711
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:32:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
03/28/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230328135159
FACILITY NAME:COMFORT CARE HOME IIFACILITY NUMBER:
157206711
ADMINISTRATOR:DHILLON, AMYFACILITY TYPE:
740
ADDRESS:9613 GHIRARDELLI DRIVETELEPHONE:
(661) 204-4455
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Administrator Amy Dhillon TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff spoke inappropriately to residents in care
INVESTIGATION FINDINGS:
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13
On 05/16/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint investigation visit and delivered finding on the above allegation. LPA was greeted by Staff Weinfredo “Wayne” Agustin and granted entry. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. Administrator Amy Dhillon arrived shortly.

During the course of the investigation, LPA conducted interviews with staff and residents which confirm S1 have spoke inappropriately to residents in care.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached Lic 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and Appeal rights was provided to the Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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-20230328135159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COMFORT CARE HOME II
FACILITY NUMBER: 157206711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87468(a)(1)
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87468(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met:
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7
Administrator stated regulations will be reviewed with staff. Documentation of staff retrained on personal rights regulations shall be submitted to Fresno CCL by 05/17/23.
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Based on interviews conducted, it was confirmed that S1 have spoken to residents in care in appropriately which poses an immediately health and safety and personal rights risk to the person 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.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
03/28/2023 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230328135159

FACILITY NAME:COMFORT CARE HOME IIFACILITY NUMBER:
157206711
ADMINISTRATOR:DHILLON, AMYFACILITY TYPE:
740
ADDRESS:9613 GHIRARDELLI DRIVETELEPHONE:
(661) 204-4455
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Administrator Amy Dhillon TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/16/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation visit and delivered finding on the above allegation. LPA was greeted by Staff Weinfredo “Wayne” Agustin and granted entry. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. Administrator Amy Dhillon arrived shortly.

During the course of the investigation, LPA conducted interviews and it is not confirmed staff hit residents in care. Therefore, based on interviews that were conducted the above allegation is founded to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3