157209103-1-13-2022-24-AS-MHON-CEYTEC-20220601143944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209103
Report Date: 01/13/2022
Date Signed: 01/13/2022 05:41:51 PM

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
01/05/2022 and conducted by Evaluator Malia Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220105082156

FACILITY NAME:	AAA RESIDENTIAL ELDERLY RETREAT		FACILITY NUMBER:	157209103
ADMINISTRATOR:	BELL, ALEXIS E		FACILITY TYPE:	740
ADDRESS:	4313 MONITOR STREET		TELEPHONE:	(661) 213-6798
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS: 6	DATE:	01/13/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Alexis Bell, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident hit another resident while in care.

INVESTIGATION FINDINGS:

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On 1/13/22 at 9:05 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA explained reason for inspection and was granted entry.

LPA reviewed records and interviewed staff and resident. Based on interviews and records review, there was not sufficient evidence to show resident hit another resident while in care. The above allegations are unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report was emailed to the email on record with "Read receipt" to confirm receipt of this report. LPA verified with ADM email on record was correct.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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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