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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206765
Report Date: 06/25/2021
Date Signed: 06/30/2021 04:08:22 PM



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
02/01/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210201090653
FACILITY NAME:NORTHLAKE VILLAFACILITY NUMBER:
247206765
ADMINISTRATOR:SITHIRAJVONGSA,VIENGSAVANHFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 761-2180
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Myra TorresTIME COMPLETED:
03:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident substained multiple pressure injuries while in care.
Resident was severly dehydrated.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/25/21 Licensing Program Analyst (LPA) M. Garza arrived at facility to delivery complaint findings. LPA met with Caregiver, Myra Torres per the instruction of Administrator, Viengsavanh "Anne" Sithirajvongsa as Administrator was unavailable.

The department conducted an investigation and interviewed staff and R1s Responsible Party (RP) and medical records were reviewed. Based on interviews conducted, R1s daughter stated, R1 had sensitive skin and did not have any pressure injuries upon entry into the facility. Staff stated R1 was repositioned often or at least every two hours, given sponge baths and given water between meals.

Based off of interviews with staff and witnesses, although the allegation may have happened or is valid there is not a preponderance of evidence that the alleged violations did occur therefore the allegations are UNSUBSTANTIATED.

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: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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