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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209256
Report Date: 09/10/2024
Date Signed: 10/07/2024 11:32:39 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
06/28/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240628115714
FACILITY NAME:VERNON GARDENS RESIDENTIAL CARE CENTERFACILITY NUMBER:
157209256
ADMINISTRATOR:CUDAL, NANCYFACILITY TYPE:
735
ADDRESS:2603 MOUNT VERNON AVENUETELEPHONE:
(661) 374-8969
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 45DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Nancy CudalTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility is dirty
Staff neglect the needs of residents
INVESTIGATION FINDINGS:
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Amended Report

Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to commence a complaint investigation. LPA discussed the purpose of the visit and the elements of the allegations with Administrator Nancy Cudal.

LPA requested a copy of R1's file. R1's did not have an LIC602 for this facility.


Based on observation, Facility resident bathroom had mold on the tile in the shower and on the shower curtain. LPA took photos.

Based on interviews and records review, Facility did not know why R1 had bandages on his legs or his diagnosis. R1 did not have an LIC602 or a needs and service plan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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 4
Control Number 24-AS-20240628115714
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: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
VISIT DATE: 09/10/2024
NARRATIVE
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Based on record review, observation and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.


A copy of this report with plan of correction and appeal rights was provided to Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20240628115714
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: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Licensee did not have
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Plan of correction Licensee agrees to submit in writing how this regulation will be met in the future by POC due date 09/11/24

Resident no longer resides in the facility.
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any documentation such as physician report, needs and service plan, home health plan or knowledge of R1's diagnosis to meet the needs of R1, which poses an immediate health safety and or personal rights risk to residents in care.
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CCR
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20240628115714
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: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2024
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by :
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Plan of Correction Licensee agrees to lock chemicals and submit photos of cleaned residents shower by POC due date 09/11/24.
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Licensee did not keep resident shower and shower curtain free of mold and did not keep bleach locked an inaccessible to residents which poses an immediate health safety and or personal rights risk 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4