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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 01/10/2024
Date Signed: 01/11/2024 09:30:51 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
12/19/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20231219084413
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: 3DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Administrator, Airen MiroTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Illegal Eviction
Residents conservator not provided Admission Agreement within seven days
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Assistant Administrator, Airen Miro and explained the purpose of today’s visit.

Regarding the allegation Illegal Eviction. Resident 1 was taken to the hospital on 12/17/23 and was denied admission back to the facility upon release. Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding the allegation Residents’ conservator not provided Admission Agreement within seven days. Resident 1’s conservator was not provided an Admission Agreement within seven days of admission to the facility. Based on LPA’s interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited Per Title 22 Regulations.
Exit interview conducted with Assistant Administrator, Airen Miro, and a copy of this report along with appeals rights 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: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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-20231219084413
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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/11/2024
Section Cited
CCR
87224(a)
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87224Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph. The following requirement has not been met as evidenced by:
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Licensee will put a procedure in place to prevent future unlawful evictions, and copy will be sent to LPA by POC due date of 01/11/24.
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Resident 1 was not accepted back into the facility after a visit to the hospital on 12/17/23, which poses an immediate, health, safety, or personal rights risk to residents in care.
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Type B
01/24/2024
Section Cited
CCR
87507(a)(c)
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87507 Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. The following requirement has not been met as evidenced by:

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Licensee will put a procedure in place to be in compliance with regulation 87505(a)(c), and copy will be sent to LPA by POC due date of 01/24/24.
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Resident 1's Conservator was not provided Admission Agreement within 7 days of living at the facility 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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2