157209103-6-24-2021-24-AS-SPIY-C4NT4E-20210706142349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209103
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:53:12 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
04/30/2021 and conducted by Evaluator Lady Cabrera

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210430084237

FACILITY NAME:	AAA RESIDENTIAL ELDERLY RETREAT		FACILITY NUMBER:	157209103
ADMINISTRATOR:	TAYLOR, SHEILA		FACILITY TYPE:	740
ADDRESS:	4313 MONITOR STREET		TELEPHONE:	(661) 213-6798
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS: 5	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Sheila Taylor, Licensee		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident has unexplained bruises
Staff is clothing the resident with double diapers.
Staff did not give the resident their pain medication
Staff refused to take resident to their medical appointment
Resident left in soiled diapers for an extended period of time
Responsible party was not notified of resident's change in condition
Staff did not provide food to resident for a long period of time
Resident has unexplained weight loss

INVESTIGATION FINDINGS:

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The Department interviewed staff and reviewed records. Facility staff denied all the above allegations. Records were reviewed and observation took place. Records reviewed found that texts supported that facility communicated with resident’s responsible party, medications were given, resident did not lose weight, and was given meals accordingly. Interviews and records reviewed also found that facility did not refuse to take resident to his medical appointments, did not clothe him in double diapers, or left him in soiled diapers. Resident’s care is charted daily. The allegations are Unfounded. Exit interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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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