247208803-5-9-2022-24-AS-SMOA-CEKVYM-20220519165123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247208803
Report Date: 05/09/2022
Date Signed: 05/09/2022 02:06:27 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
03/16/2022 and conducted by Evaluator Mai Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220316170103

FACILITY NAME:	WESTSIDE ELDERLY CARE I		FACILITY NUMBER:	247208803
ADMINISTRATOR:	TOSTADO, MARIA H		FACILITY TYPE:	740
ADDRESS:	1243 SANTA MARIA		TELEPHONE:	(209) 827-0142
CITY:	LOS BANOS	STATE: CA	ZIP CODE:	93635
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2022
		UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Administrator, Maria Tostado		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Neglect/ lack of supervision resulted in resident sustaining a fracture.
Resident developed pressure injuries while in care.
Resident is dehydrated.

INVESTIGATION FINDINGS:

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On 05/09/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Administrator Maria Tostado.

The Department conducted interviews with staff, residents, and reviewed file and medical records. Per medical records reviewed, resident had a fracture that was age-indeterminate, therefore it is unknown whether it is an old or new fracture. Medical records also stated resident did not have any skin breakdown or wound/ulcer problems. Facility staff denied the allegations.

There is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are Unsubstantiated. Exit interview was conducted. Copy of this report was provided to the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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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