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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208933
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:46:45 AM

Unsubstantiated


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
05/14/2021 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20210514101455
FACILITY NAME:NEMIA HOMEFACILITY NUMBER:
157208933
ADMINISTRATOR:ROGER PALIGUTANFACILITY TYPE:
734
ADDRESS:3256 JENKINS RDTELEPHONE:
(650) 238-4987
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:5CENSUS: 5DATE:
09/13/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michelle ManganaanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA identified herself and explained the purpose of the visit was to deliver findings to Administrator Michelle Manganaan .

LPA interviewed staff and reviewed medical records. After interviewing staff and reviewing medical records, it was found that the C1 can bruise easily due to the medications administered to C1.

Although the allegations Resident sustained unexplained bruising while in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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