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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247208803
Report Date: 12/16/2022
Date Signed: 01/27/2023 11:27:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
10/21/2022 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221021143403
FACILITY NAME:WESTSIDE ELDERLY CARE IFACILITY NUMBER:
247208803
ADMINISTRATOR:TOSTADO, MARIA HFACILITY TYPE:
740
ADDRESS:1243 SANTA MARIATELEPHONE:
(209) 826-7120
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:6CENSUS: 6DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator- Maria Tostado TIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Resident sustained injury due to staff handling resident in a rough manner
Staff are not meeting residents diapering needs
Staff are not feeding residents dinner at an appropriate times
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to deliver the complaint
investigation findings. LPA met with Caregiver Antonia Dominguez and explained the purpose of the
visit. Administrator (AD) Maria Tostado was contacted and arrived shortly after.
1. The Department investigated the allegation: Resident sustained injury due to staff handling resident in a rough manner. After conducting multiple interviews and reviewing records it was found some residents were handled in a rough manner at times, leading to excessive or unexplained bruising.
2. The Department investigated the allegation: Staff are not meeting residents diapering needs. After conducting multiple interviews and reviewing records there were various times “diapering needs” were not being met properly.
3. The department investigated the allegation: Staff are not feeding residents dinner at an appropriate time. Multiple interviews were conducted, and records reviewed indicating dinner was being served at an “early time”.
See LIC9099-C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20221021143403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: WESTSIDE ELDERLY CARE I
FACILITY NUMBER: 247208803
VISIT DATE: 12/16/2022
NARRATIVE
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Findings for these allegations were from gathered information from reviewing various records and conducting various interviews with witnesses.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099D. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted, and a copy of this report dated 12/16/2022 along with 9099A & 9099D. Plan of Correction (POC) were discussed. Appeal Rights (LIC 9058) was provided to Administrator Maria Tostado whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20221021143403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WESTSIDE ELDERLY CARE I
FACILITY NUMBER: 247208803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Administrator will conduct training on properly cleaning and briefing the residents. Administrator will create a plan so residents can be assisted with bathroom needs in a timely manner. Verification will be provided to LPA.
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Based on interviews and record reviews licensee failed to ensure each resident’s personal rights were being met which resulted in infections. This poses a potential health, safety, or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
10/21/2022 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221021143403

FACILITY NAME:WESTSIDE ELDERLY CARE IFACILITY NUMBER:
247208803
ADMINISTRATOR:TOSTADO, MARIA HFACILITY TYPE:
740
ADDRESS:1243 SANTA MARIATELEPHONE:
(209) 826-7120
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:6CENSUS: 6DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator- Maria Tostado TIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff are not rotating resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to deliver the complaint
investigation findings. LPA met with Caregiver Antonia Dominguez and explained the purpose of the
visit. Administrator (AD) Maria Tostado was contacted and arrived shortly after.

Based on interviews conducted and record review, the above allegation is UNSUBSTANTIATED. Although
the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the
alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Documents and interviews provided information to substantiate 3 of the 4 allegations. For the allegation of "Staff are not rotating resident in a timely manner" complainant was interviewed and stated there were no issues of rotating the residents, no other interviewees had complaints regarding this allegation. Complainant initially alleged "Staff are not rotating resident in a timely manner", but later retracted the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4