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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 12/01/2023
Date Signed: 12/15/2023 12:06:51 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
05/11/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230511143721
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:
12/01/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator Airen Miro TIME COMPLETED:
11:30 AM
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 Brianna Miranda arrived unannounced to deliver findings on the above allegatuons on 12/01/23 at 10:00 a.m.. LPA's met with facility Assistant Administrator Airen Miro and stated the purpose of the visit.

Regarding the allegation Staff did not issue a refund. Resident 1 provided proof of two paid fees to Licensee totaling $1,855.00 in two separate payments dated on 08/01/2022 (Admission fee $500), and on 08/16/2022 (holding fee $1,355.00.) Resident 1 never moved into the facility. Licensee refunded Resident 1 $500 of the fees paid. The Admission Agreement does not speak to any non refundable "holding" fees. 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 deficincies are being cited Per Title 22 Regulations.
Exit interview conducted with Assistant Administrator Airen Miro, and a copy of this report provided.
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: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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-20230511143721
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: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
87507(g)(3)(C)
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Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified.
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Licensee will submit proof of refund of the $1,355.00 holding fee to the RP by 12/15/23 POC date.
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 **This requirement was not met as evidenced by review of the admission agreement provided to RP, that did not specify a $1,355.00 holding fee.
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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: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
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