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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 04:07:11 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: 11DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Myra TorresTIME COMPLETED:
03:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not see resident timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The department conducted an investigation. Interviews were conducted with facility staff and home health registered nurse. Home health nurse denied that R1 was neglected. They stated that wound care was being followed from 12/7/20 to 1/18/21.

Facility staff confirmed that paramedics were contacted when R1 needed to go to the hospital to receive care. Facility staff confirmed that R1’s care was monitored and that R1’s declining health was documented.

The allegation is UNFOUNDED.
Unfounded
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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