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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208915
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:31:22 AM

Substantiated


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
03/30/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230330093440
FACILITY NAME:PALMS AT SAN LAUREN, THEFACILITY NUMBER:
157208915
ADMINISTRATOR:RICE, DOUGLASFACILITY TYPE:
740
ADDRESS:5300 HAGEMAN RDTELEPHONE:
(661) 218-8333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY:68CENSUS: 65DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Administrator Douglas RiceTIME COMPLETED:
08:42 AM
ALLEGATION(S):
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Facility staff were not present at the facility.
Facility staff did not respond to a resident's pull chord for assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)'s Shawna Doucette and Darius Williams conducted a visit to commence a complaint investigation and deliver findings. LPA's identified themselves and discussed the purpose of the visit and the elements of the allegations with Administrator Douglas Rice.

LPA requested records for pull chord history from 3/15/23 to 3/31/23 at which Administrator stated he was unable to provide due to the system recording over every 2 days. Administrator submitted days of 4/7/23 and 4/8/23. LPA interviewed staff, residents, and witnesses. LPA obtained a copy of the Fire Departments report regarding this incident.

Based on records review and interviews, facility had one staff on duty who was not present at the facility for approximately 30 minutes. Facility staff did not answer pull chords for residents in care.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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-20230330093440
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: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
VISIT DATE: 06/08/2023
NARRATIVE
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Based on the Departments record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety 1569.49 (c)(3) is being cited on the attached LIC 9099D. Civil penalty was issued.

Citation for 87411(a) is being cited on 24-AS-20230321111428.

Refer to Case Management on 6/8/23 for additional deficiencies.

An exit interview was conducted with Administrator, a copy of this report with plan of corrections, and appeal rights were provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230330093440
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: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
HSC
1569.49(c)(3)
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1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for
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Plan of Correction POC Facility agrees to submit a plan to have suffiecient staff and to train staff on emergency procedures for emergency leave by POC due date 06/9/23. Licensee will submit staff training by 6/30/23.
Civil Penalty was issued.
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 each day the violation continues after citation for any of the following serious violations:(3) Absence of supervision as required by statute or regulation. This regulation was not met as evidenced by: On 03/29/23 Facility did not have staff present in the faciltiy and did not provide care to R1 for at least 30 minutes which poses an immediate health, safety, and/or personnnel rights risks to residents 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3