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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209150
Report Date: 05/09/2024
Date Signed: 05/13/2024 08:20:07 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
02/07/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240207140456
FACILITY NAME:GOLDEN YEARS RESIDENTIAL CARE HOME, THEFACILITY NUMBER:
207209150
ADMINISTRATOR:LUARES, BERNARDINOFACILITY TYPE:
740
ADDRESS:160 S 13TH STREETTELEPHONE:
(707) 235-2717
CITY:CHOWCHILLASTATE: CAZIP CODE:
93610
CAPACITY:41CENSUS: 40DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Elizabeth Prasad TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility staff did not notify resident's responsible person of incident(s)
Facility staff did not assist resident with grooming as needed.
Facility staff did not ensure resident wears clean clothing.
Facility staff did not assist resident with bathing as needed.
Facility staff did not provide adequate meal service.
Facility staff did not ensure resident(s) can use call light.
Facility staff did not arrange for medical care as needed.
Facility lobby floors not maintained clean.
INVESTIGATION FINDINGS:
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On 5/09/2024, Licensing Program Analyst (LPA) V Gorban visited facility to deliver findings.
During this visit LPA met with facility supervisor John Alfelor and Licensee Elizabeth Prasad and toured the facility inside and out and observed residents in care. Once the tour was complete findings discussed.
Allegation: Facility staff did not notify resident's responsible person of incident(s). Based of records review provided facility notified responsible party. 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.

Allegation: Facility staff did not assist resident with grooming as needed. Based of staff and residents interviews, resident’s file review R1 is independent so did not requeted assistance with grooming. 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.
Report continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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-20240207140456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 207209150
VISIT DATE: 05/09/2024
NARRATIVE
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This is an amended report.

Allegation: Facility staff did not ensure resident wears clean clothing. Based of files review, staff and residents’ interview, facility offer laundry twice a week to all residents, no concerns from residents interviewed. 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.

Allegation: Facility staff did not assist resident with bathing as needed. Based of files review, residents and staff interviews R1 was able to bath self with assistance, R1's refused baths documented on file. 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.

Allegation: Facility staff did not provide adequate meal service. Based off history and facility file review and residents interview no concerns of inadequate meals at the facility reported by residents or observed by LPA. Alternative meals offered by facility. 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.

Allegation: Facility staff did not ensure resident(s) can use call light. Based of records review R1 is ambulatory and independent. 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.

Allegation: Facility staff did not arrange for medical care as needed. Based of interviews and resident’s file review R1 was provided arrangements and services by alternative department who arranged her medical needs. 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.

Allegation: Facility lobby floors not maintained clean. During both facility visits on 2/15, 5/09, and observations of the facility lobby floors appear clean, free of clutter, and odorless. 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.

Exit interview provided, report signed and copy of this report provided for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
02/07/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240207140456

FACILITY NAME:GOLDEN YEARS RESIDENTIAL CARE HOME, THEFACILITY NUMBER:
207209150
ADMINISTRATOR:LUARES, BERNARDINOFACILITY TYPE:
740
ADDRESS:160 S 13TH STREETTELEPHONE:
(707) 235-2717
CITY:CHOWCHILLASTATE: CAZIP CODE:
93610
CAPACITY:41CENSUS: 40DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Elizabeth Prasad TIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility staff did not ensure resident's room is maintained clean.
INVESTIGATION FINDINGS:
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This is an amended report.
On 5/09/2024, Licensing Program Analyst (LPA) V Gorban visited facility to deliver findings.
During this visit LPA met with facility supervisor John Alfelor and Licensee Elizabeth Prasad and toured the facility inside and out and observed residents in care. Once the tour was complete findings discussed.
Allegation: Facility staff did not ensure resident's room is maintained clean.

During residents and staff interview no concerns of rooms not being cleaned although RP provided records of ants in the room during the R1 visit. Based on observations and interviews which were conducted during the facility visit on 2/15/24 and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division being cited on the attached LIC 9099-D.

Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240207140456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 207209150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87303a
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not observed as evidenced by:
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The facility offered as a plan of correction to provide receipt for all facility treatment twice in a row, receipt will be provided to LPA via email by POC due date.
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The facility failed to maintain clean table counter tops and floors in the facility that did not appear clean and free from clutter. This poses potential health and safety 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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4