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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209058
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:20:57 PM

Unsubstantiated


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
12/05/2022 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221205130046
FACILITY NAME:CHRISTINA'S HOME CAREFACILITY NUMBER:
247209058
ADMINISTRATOR:PELAYO, CHRISTINAFACILITY TYPE:
740
ADDRESS:8397 KIMBERLY WAYTELEPHONE:
(209) 485-6940
CITY:HILMARSTATE: CAZIP CODE:
95324
CAPACITY:6CENSUS: 5DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Christina PelayoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff made inappropriate comments to residents in care.
Facility staff are not adequately providing care and supervision to residents at night.
INVESTIGATION FINDINGS:
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On 03/07/22 Licensing Program Analyst (LPA) V Gorban visited facility stated above to report findings pertaining to investigation with allegations:

Allegation: Facility staff made inappropriate comments to residents in care

Finding: Based on interviews, file reviews and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Facility staff are not adequately providing care and supervision to residents at night.


.....continuation of the visit is on LIC9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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 2
Control Number 24-AS-20221205130046
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: CHRISTINA'S HOME CARE
FACILITY NUMBER: 247209058
VISIT DATE: 03/07/2023
NARRATIVE
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Finding: Based on interviews and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted. Report is signed by Administrator and copy left with administrator for facility for records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2