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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209040
Report Date: 10/04/2022
Date Signed: 10/04/2022 04:05:04 PM

Substantiated


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 Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220316141215
FACILITY NAME:SAN SIMEON BOARD AND CAREFACILITY NUMBER:
247209040
ADMINISTRATOR:KALINGA, ADELINAFACILITY TYPE:
740
ADDRESS:1437 SAN SIMEON COURTTELEPHONE:
(209) 349-8302
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 5DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arnel Amor Tolentino, StaffTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Lack of supervision resulted in resident sustaining a fracture
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera delivered investigation findings regarding the above allegation. Administrator Adelina Kalinga was unavailable and designated Staff Arnel Amor Tolentino to meet with LPA and sign this report. The Department has investigated the complaint alleging: Lack of supervision resulted in resident sustaining a fracture. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED.

Per Mercy Medical Records, Resident sustained multiple rib fractures on the left side.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.

Exit interview conducted and copy of this report was provided with the Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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 5
Control Number 24-AS-20220316141215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAN SIMEON BOARD AND CARE
FACILITY NUMBER: 247209040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by:
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Licensee will submit written statement by 10/05/2022 indicating when she will conduct training for care and supervision for all staff.
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Based on the Department's investigation, Licensee did not meet the above regulation, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220316141215

FACILITY NAME:SAN SIMEON BOARD AND CAREFACILITY NUMBER:
247209040
ADMINISTRATOR:KALINGA, ADELINAFACILITY TYPE:
740
ADDRESS:1437 SAN SIMEON COURTTELEPHONE:
(209) 349-8302
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 5DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arnel Amor Tolentino, StaffTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care
Staff yells at the residents
Staff do not provide adequate food service to the residents
Staff behavior poses as a risk to the residents
Residents are left soiled for an extended periods of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility. Administrator Adelina Kalinga was unavailable and designated Staff Arnel Amor Tolentino to meet with LPA and sign this report. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Resident developed multiple pressure injuries while in care, Staff yells at the residents, Staff do not provide adequate food service to the residents, Staff behavior poses as a risk to the residents and Residents are left soiled for an extended periods of time. Based on the interviews conducted and records reviewed the above allegations are UNSUBSTANTIATED.

On 02/17/2022, Resident (R3) was diagnosis with Stage two pressure ulcer. Per Home Health records, staff were trained and educated regarding R3’s condition. On 05/03/2022, R3 was discharged from home health due to the wound was healed. Per home health interview, all caregivers were competent in caring for R3’s wound. Per interviews and facility records, R3 was repositioned and would be change every two hours or more when needed. At this time, R3 has not developed another wound.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220316141215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SAN SIMEON BOARD AND CARE
FACILITY NUMBER: 247209040
VISIT DATE: 10/04/2022
NARRATIVE
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Per complainant, it was reported that staff yells at residents. LPA conducted staff and residents’ interviews. A total of three out of five residents have hearing loss and have a hearing aid. On 07/22/2022, LPA observed two residents without their hearing aids. It was reported that residents at times will not wear it. Staff will have to raise their voice in order to communicate with residents that are not wearing their hearing aids.

It was reported Staff do not provide adequate food service to the residents. On 07/22/2022, LPA conducted facility tour and observed a 2-day supply of perishable and 7-day supply of non-perishable food. LPA observed residents’ dinner on the kitchen stove top.

Complainant reported Staff behavior poses as a risk to the residents. This allegation was referring to facility had staffing issues and staff did not have days off. Based on interviews conducted staff denied sleeping at facility, staff reported they were able to meet resident needs and their behavior did not pose a risk to the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and Appeal Rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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 Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220316141215

FACILITY NAME:SAN SIMEON BOARD AND CAREFACILITY NUMBER:
247209040
ADMINISTRATOR:KALINGA, ADELINAFACILITY TYPE:
740
ADDRESS:1437 SAN SIMEON COURTTELEPHONE:
(209) 349-8302
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 5DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Arnel Amor Tolentino, StaffTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff leave residents unattended while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility. Administrator Adelina Kalinga was unavailable and designated Staff Arnel Amor Tolentino to meet with LPA and sign this report.

During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Staff leave residents unattended while in care is UNFOUNDED.

Complainant reported that they did not mention or report that the staff will leave the residents. Per interviews conducted it was reported that there are always staff in the facility caring for the residents. This agency has investigated the complaint alleging (Staff leave residents unattended while in care). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5