247209209-8-3-2023-24-AS-BCHN-CUJ27N-20230808170900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 07/28/2023
Date Signed: 08/03/2023 08:51:32 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
07/25/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230725122932

FACILITY NAME:	ATWATER RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	247209209
ADMINISTRATOR:	JOHNSON, JESSICA		FACILITY TYPE:	740
ADDRESS:	1691 JOE SILVA AVENUE		TELEPHONE:	(209) 430-1688
CITY:	ATWATER	STATE: CA	ZIP CODE:	95301
CAPACITY:	5	CENSUS: 3	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Facility Licensee, Jessica Johnson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff was unable to communicate due to language barrier
Staff are not properly maintaining resident’s medical records

INVESTIGATION FINDINGS:

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On 07/28/2023, Licensing Program Analysts(LPA's) Sarah Hurt and Lisa Salazar arrived at the facility unannounced to conduct an initial 10-day complaint inspection. LPAs met with facility Licensee Jessica Johnson announced the purpose of the inspection.

Regarding the allegation Staff was unable to communicate due to language barrier.LPA's observed facility Staff 1 present during visit is unable to communicate with licensing staff or facility residents as she does not speak English. Based on LPA's observation during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Continued on 9099C..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 3

Control Number 24-AS-20230725122932

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
	VISIT DATE: 07/28/2023

NARRATIVE

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Continued from 9099...

Regarding the allegation staff are not properly maintaining resident’s medical records. Licensee was unable to provide requested records for Resident 1. Licensee stated the records were not provided with Resident 1 at the time of Admission on July 14, 2023. Based on LPA's interviews during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

The following deficiencies are being cited per Title 22 Regulations.

Exit interview conducted with Licensee Jessica Johnson. A copy of this report along with appeal rights provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230725122932

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/29/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to have staff present at all that can communicate with facility residents and send proof to LPA by POC date of 07/29/2023.
	8 9 10 11 12 13 14	LPA's observed Staff 1 did not speak english, and was unable to communicate with Licensing staff, and facility residents, which poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 07/29/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide requested records for Resident 1 and send proof to LPA by 07/29/2023 POC date.
	8 9 10 11 12 13 14	Based on interviews with Licensee, Resident 1 does not have any records and non were provided at the time of Resident 1's admission, which poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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