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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247206765
Report Date: 07/14/2022
Date Signed: 07/14/2022 02:26:25 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
05/06/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220506162538
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:0CENSUS: 13DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:House Manager, Maria KnightTIME COMPLETED:
02:51 PM
ALLEGATION(S):
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9
Resident sustained multiple injuries while in care
INVESTIGATION FINDINGS:
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2
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13
On 7/14/2022 Licensing Program Analyst M. Garza arrived at facility to deliver complaint findings. LPA was temperature screened and allowed entry into the facility by Direct Care Staff, Tinny Daraphet. House Manager, Maria Knight was contacted and arrived some time later. LPA explained reason for visit and completed a Health and Safety check on residents in care. Residents observed in common areas and in rooms.

During investigation IB requested and reviewed medical records. Although falls resulting in an injury occured, the faciilty attempted to prevent further falls. Facility did so by installing rails in the bathroom, covered corners of furniture with corner covers, lowering bed and installed side rails. Althought the allegation may have occurred it was not due to a lack of care and supervision. The allegation is UNSUBSTANTIATED.

Exit interview completed and a copy of the report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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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