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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209322
Report Date: 11/08/2024
Date Signed: 11/08/2024 05:19:00 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
07/08/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240708092417
FACILITY NAME:AAA RESIDENTIAL ELDERLY RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR:DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 412-7266
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: 2DATE:
11/08/2024
UNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Administrator Sheila DillardTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not transport resident to medical appointment in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)'s Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Sheila Dillard. LPA's explained the purpose of the visit.

LPA conducted interviews and reviewed records.

Based on interviews, LPA is unable to determine if there was a time staff refused to take a resident to a medical appointment.

Based on record reviews and interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
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 3
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
07/08/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240708092417

FACILITY NAME:AAA RESIDENTIAL ELDERLY RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR:DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 412-7266
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: 2DATE:
11/08/2024
UNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Administrator Sheila DillardTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death.
Staff did not inform resident's responsible party of resident's change in condition.
Staff did not address resident's change in condition
INVESTIGATION FINDINGS:
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3
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5
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12
13
Licensing Program Analysts (LPA)'s Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Sheila Dillard. LPA's explained the purpose of the visit.

Based on the coroners report R1 passed away from natural causes.

Based on record review and interviews, R1 was sent to the hospital on multiple times in the month of June 2024. Resident was scheduled for a doctor appointment on 7/2/24. LPA was unable to determine if an appointment was missed.


Based on interviews, Responsible party was notified of residents change in condition. LPA reviewed text messages between Licensee and responsible party.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240708092417
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: AAA RESIDENTIAL ELDERLY RETREAT #3
FACILITY NUMBER: 157209322
VISIT DATE: 11/08/2024
NARRATIVE
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Based on the Departments interviews and record review, this agency has investigated the complaint alleging, Questionable Death,Staff did not inform resident's responsible party of resident's change in condition and
Staff did not address resident's change in condition We have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3