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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208915
Report Date: 03/19/2021
Date Signed: 03/19/2021 01:15:49 PM



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
11/20/2020 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20201120105920
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: 39DATE:
03/19/2021
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Douglas Rice, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff failed to treat resident with dignity and respect
INVESTIGATION FINDINGS:
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On 3/19/2021, Licensing Program Analyst (LPA) A. Walton contacted Administrator, Douglas Rice to deliver findings on the above allegation via telephone due to COVID-19 and precautionary measures. LPA introduced self and stated the purpose of the call with the Administrator.

LPA conducted staff interviews, reviewed personnel records and staff training, and observed a video recording. It was concluded that on 10/21/2020, S3 provided a facility phone to S1 and S2 to record the behavior of R1 without consent. S1 and S2 were observed to be laughing and failed to appropriately redirect R1.

Based on interviews, records reviews, and observation of a video recording, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Continued to LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
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-20201120105920
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: 03/19/2021
NARRATIVE
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Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099D.

An exit interview was conducted with Administrator, Douglas Rice. Appeal Rights and a copy of this report was discussed and provided via email and an electronic read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20201120105920
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: 03/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities(a)(1): Residents...shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents and other persons.
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Licensee will submit a plan detailing steps on how facility will ensure residents are accorded dignity in their personal relationships.
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This requirement was not met as evidenced by: Based on observation of a video recording and staff interviews, Licensee did not ensure residents were accorded dignity in their relationships with staff, when on 10/21/2020, staff recorded the behavior of R1 without consent and did not appropriately redirect R1. This poses a potential health and safety risk to persons in care.
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Licensee stated that staff will be trained on requirements of Personal Rights of Residents in All Facilities.

Documentation of training topics and attendance will be submitted to the Fresno CCL office by 4/19/2021.
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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3