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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247202427
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:41:52 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
08/31/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210831135132
FACILITY NAME:TERRIE'S TLC SENIOR HOME IIFACILITY NUMBER:
247202427
ADMINISTRATOR:RHODES, THERESE ANNEFACILITY TYPE:
740
ADDRESS:1317 E BROOKDALE DR.TELEPHONE:
(209) 726-0548
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 1DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Therese RhodesTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident fell while in care.
Resident sustained bed sore while in care.
Resident left in soiled diaper for a period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/24/2022 Licensing Program (LPA) M. Garza arrived at facility unannounced to deliver complaint findings. LPA was met by facility staff, Christine Jarvise. Licensee was contacted and arrived a short time later. LPA was COVID pre-screened prior to entry to facility. LPA allowed entry to facility and advised reason for visit. LPA toured facility. LPA completed health and safety check on 1 resident in care. Resident observed in common area watching television.

During the investigation interviews were completed (staff, licensee and reporting party), documentation was reviewed and collected. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations listed above did or did not occur therefore the allegations are UNSUBSTANTIATED.

An exit interview was completed with Licensee. A copy of this report provided. No deficiencies cited for the above allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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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