247209209-10-30-2023-24-AS-BCHN-CYGQDE-20231213110435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 10/25/2023
Date Signed: 10/30/2023 01:57:44 PM

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
03/20/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230320135406

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:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Jessica Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not meet a resident's incontinence needs while in care
Staff did not prevent a resident from causing harm to other residents
Staff did not properly reports incidents involving a resident
Staff are not providing adequate care and supervision to a resident
Staff mishandled a resident's medication while in care
Staff is not following the admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Sarah Hurt and Darius Williams conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Licensee Jessica Johnson over the phone and explained the purpose of today’s visit.

Regarding the allegation, Staff did not meet a resident's incontinence needs while in care. LPA Hurt observed several photos documenting Resident 1’s buttocks area to be extremely red and irritated. Medical records document Resident 1 had erythema and pain in the buttocks area. Based on records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Continued....

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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230320135406

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: 10/25/2023

NARRATIVE

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Regarding the allegation Staff did not prevent a resident from causing harm to other residents. Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. LPA Hurt reviewed several text and email exchanges between facility Administrator and Resident 1’s Responsible Party documenting incidents of Resident 1 hitting other facility residents. Based on records reviewed the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Regarding the allegation Staff did not properly report incidents involving a resident. LPA Hurt reviewed medical records documenting Resident 1 was taken to the hospital on 02/06/2023, this incident was not reported to State Licensing. LPA Hurt observed text messages dated March 4, 2023 documenting Resident 1 assaulted another facility resident. This incident was not reported to State Licensing. This incident from March 4, 2023 was not reported to State Licensing. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Regarding the allegation Staff are not providing adequate care and supervision to a resident. LPA Hurt reviewed Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. Staff 1 stated at times working alone with 4 residents providing all care and supervision, meals, and incontinent needs made it difficult to provide supervision. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230320135406

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: 10/25/2023

NARRATIVE

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Regarding the allegation Staff mishandled a resident's medication while in care. LPA reviewed Centrally Stored Medication log for Resident 1 documenting a medication with a start date of 01/01/2023 with no quantity, date filled, expiration date, or Pharmacy name. The medication is not documented on any Medication Administration Record. It is unclear if this medication was given to Resident 1 at the facility. Based on LPA observation, and records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Regarding the allegation Staff is not following the admission agreement. Admission agreement documents under section “Notice of Rate Changes." If the facility rate for basic services changes because the resident’s needed/desired services changes as determined by an appraisal (see resident appraisals / evaluation of your needs), the rate change will occur when the change in service occurs, as long as at least thirty days have passed since the signing of the admission agreement. We shall provide the resident or the representative a written itemized notice of a rate increase after the change in services which will include a detailed itemized explanation of the additional services to be provided. Responsible Party for Resident 1 was not given a detailed itemized explanation of the additional services provided. The invoice provided is not dated. Based on Records reviewed 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, and a copy of this report provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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
03/20/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230320135406

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:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Jessica Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not properly groom a resident while in care
Resident sustained multiple injuries while in care
Staff disclosed confidential information
Staff are falsifying a resident's medical records
Staff did not provide an authorized representative access to a resident's records

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 9

Control Number 24-AS-20230320135406

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: 10/25/2023

NARRATIVE

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Continued..
Regarding the allegation Resident sustained multiple injuries while in care. Resident 1 did have documented bruising during a visit to his Physician on 02/13/2023. Resident 1 also had documented un-witnessed falls. Facility staff documented Resident 1 was refusing to use his wheelchair, and walker. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time.

Regarding the allegation Staff disclosed confidential information. Licensee did text Responsible Party for Resident 1 asking if their contact information can be given to the Responsible Parties of other residents. Resident 1’s Responsible party was not contacted by any other residents Responsible Parties. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time.

Regarding the allegation Staff are falsifying a resident's medical records. Facility staff documented Resident 1’s medication given three times daily once at 4 p.m. despite Resident 1 leaving for the hospital at approximately 3 p.m. Facility staff did give Resident 1 his medication as listed on the prescription despite it not being the exact time. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time.

Regarding the allegation Staff did not provide an authorized representative access to resident records. LPA reviewed text messages between Resident 1's Responsible Party, and Licensee Jessica Johnson discussing Resident 1's records. Based on these messages it is unclear when the documents were originally requested, and who requested the records. A written request was not given to Licensee requesting Resident 1's records. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time.

No Deficiencies Cited Per Title 22 Regulations.

Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 24-AS-20230320135406

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: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2023 Section Cited HSC 1569.2	1 2 3 4 5 6 7	(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide training to all facility staff on Care and Supervision of residents, and provide proof to LPA by POC date of 10/26/2023.
	8 9 10 11 12 13 14	Resident 1 attacked several other 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 10/26/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan documenting how she is going to ensure residents medications will be refilled, dispersed and provided to residents per physician’s orders by POC date.
	8 9 10 11 12 13 14	Resident 1's Centrally Stored Medication Log lists medications with no quantity 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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 24-AS-20230320135406

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: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/09/2023 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s represent ative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will re submit invoice #100 to include a detailed explanation of additional services to provided at the new level of care and accompanying itemization of the charges to CCL by POC date of 10/24/2023.
	8 9 10 11 12 13 14	Licensee did not provide Resident 1's responsible party a detailed written breakdown of services provided , and it is not clear when invoice was given, which poses a potential, health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 24-AS-20230320135406

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: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2023 Section Cited CCR 87265(b)(7)	1 2 3 4 5 6 7	87265 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (7) Ensuring that the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee shall provide documentation and training on how staff will evaluate residents regularly to ensure skin breakdown is not occurring and submit proof to LPA Hurt by POC date 10/26/2023.
	8 9 10 11 12 13 14	Records, and photos document Resident 1's buttocks area was extremely red and irritated over a period of weeks, which poses an immediate, health, safety or personal rights risk to resident in care.	8 9 10 11 12 13 14
Type B 11/02/2023 Section Cited CCR 87211(1)(D)	1 2 3 4 5 6 7	87211Reporting Requirements e shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit proof of regulation understanding to LPA Hurt by POC date of 11/02/2023.
	8 9 10 11 12 13 14	LPA reviewed records of incidents on 03/09/2023 that was not reported to State Licensing which poses a potential, 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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 9

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
03/20/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230320135406

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:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Jessica Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not issue a refund

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Sarah Hurt and Darius Williams conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Licensee Jessica Johnson and explained the purpose of today’s visit.

Regarding the allegation Staff did not issue a refund. Admission Agreement signed by Responsible party for Resident 1 documents “thirty days written notice to move from the facility is required.” Responsible Party for Resident 1 did not give required thirty days notice before moving from the facility. Based on interviews, and records reviewed during this investigation we have found that the complaint was unfounded, meaning that the allegation is false, could not have happened and/or is without reasonable basis, therefore, we have dismissed the complaint.

No Deficiencies Cited Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.

Unfounded

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: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 9 of 9