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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 02/27/2023
Date Signed: 03/02/2023 09:25:48 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
11/15/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20221115100653
FACILITY NAME:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 4DATE:
02/27/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Jessica JohnsonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide the resident’s representative written notice of the rate increase within two business days after initially providing services at the new level of care
Staff did not refund authorized representative after resident's passing
Staff refused to allow authorized representative in the facility to pick up residents belongings
Staff did not provide a comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed in the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a complaint investigation. LPA Hurt met with Administrator Jessica Johnson and explained the purpose of today's visit.

Regarding the allegation Staff did not provide the resident’s representative written notice of the rate increase within two business days after initially providing services at the new level of care. The facility Admissions Agreement documents under section "Notice of Rate Changes." We shall provide the resident or the representatives a written itemized explanation of the additional services provided. Resident 1's responsible party stated they were given the written description through email on 11/18/2022 after the verbal notification of increased rate on 11/04/2022. Based on facility records reviewed, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Continued on 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
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 4
Control Number 24-AS-20221115100653
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: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
VISIT DATE: 02/27/2023
NARRATIVE
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....Continued from 9099

Regarding the allegation staff did not refund authorized representative after resident's passing. The facility Admission's Agreement documents under "Death of a Resident." Within fifteen days after your personal property is removed from the facility, your estate, or other person or entity responsible for payment of fees and charges under this Agreement will receive a refund any fees paid in advance covering the period after your personal property has been removed. The licensee shall, within 3 days of becoming aware of a residents death, provide a written notice to specified persons of the facility's policies regarding contract termination at death and refunds. The facility Administrator Jessica Johnson has not provided a refund to Resident 1's Responsible Party more than 15 days after their passing. Based on facility records reviewed, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff refused to allow authorized representative in the facility to pick up resident’s
belongings. After the passing of Resident 1 on 11/12/2023 the facility Administrator Jessica Johnson did not allow Resident 1's responsible party to enter the facility on 11/13/2022 to gather their belongings. The facility Admission's Agreement documents "Upon your death, your personal property is removed at any time by appointment or between the hours of 8 a.m. to 5 p.m. Monday through Friday, by your responsible person, by other persons whom you have designated in writing in this Agreement, or by a court appointed executor or administrator of your estate, if applicable. Based on facility records reviewed, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff did not provide a comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed in the admission agreement. Based on interviews conducted the facility Administrator Jessica Johnson did not provide a description of services provided under a single fee until 11/18/2022, 14 days after the higher rate began for these services and she was verbally notified on 11/04/2022 . Based on facility records reviewed, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited today Per Title 22 Regulations.

Exit interview conducted with facility Administrator Jessica Johnson, and copy of report provided along with appeals rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20221115100653
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: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited
CCR
87507(f)
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87507((f)The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. The following requirement has not been met as evidenced by:
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Administrator Jessica Johnson will provide written Statement of Understanding of Regualtion 87507 (f) and submit to LPA Hurt by POC date of 03/14/2023.
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The facility Administrator did not provide written notice of rate increase within two days as stated in signed facility Admissions Agreement, which poses a potential, health, safety or personal rights risk to residents in care.
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Request Denied
Type B
03/14/2023
Section Cited
HSC
1569.652(a)
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Health and Safety Code section 1569.652 provides in part:(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. The following requirement has not been met as evidenced by:
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Administrator Jessica Johnson will issue refund to Resident 1's responsible party for pro rated days after his passing and submit proof to LPA by POC date of 03/14/2023.
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Resident 1's responsible party has not been refunded after passing on 11/12/2023 which 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: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20221115100653
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: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited
CCR
87507(g)(A)1.
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87507 Admission Agreement (g) Admission agreements shall specify the following:(1) Basic services, as defined in Section 87101(b), (A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including: 1A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed. The following requirement has not been met as evidenced by:
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Administrator Jessica Johnson will provide written Statement of Understanding of Regualtion 87507 (g)(A) and submit to LPA Hurt by POC date of 03/14/2023.
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Administrator did not give detailed itemized description of fees until 14 days after change of condition and rate increase, which 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: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4