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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 10:22:43 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
06/12/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230612142552
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:
12:15 PM
MET WITH:Assistant Administrator, Airen MiroTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not adequately staffed resulting in the facility calling the fire department for assistance.
Facility staff engaged in a verbal altercation with a resident.
Facility staff left resident in urine soaked clothing for an extended period of time.
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 the facility is not adequately staffed resulting in the facility calling the fire department for assistance. Emergency Medical Personnel provided a log with more than 21 dates listed where they have been asked to assist Residents in the facility that have fallen, and residents who need assistance getting up from being seated in a recliner to different areas of the facility. Based on interviews conducted during this investigation, and call logs reviewed 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 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 4
Control Number 24-AS-20230612142552
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: 01/10/2024
NARRATIVE
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Regarding the allegation Facility staff engaged in a verbal altercation with a resident. Witness 1 stated they were called to assist at the facility, when they arrived they spoke with a facility caretaker who requested they take the resident’s phone. Witness 1 stated they spoke with the resident, who seemed to be coherent and was just saying they didn’t want to be at the facility because they weren’t being treated right and they wanted to go to the hospital. Witness 1 stated they witnessed the caregiver trying to rip the phone from the resident’s hand. Witness 1 stated caregiver then made a phone call and then the caregiver stated the Resident’s daughter told the caregiver to take the phone away from the resident. Witness 1 again stated they weren’t going to take the phone away as it was the residents’ only line of communication. Witness 1 stated they then witnessed the Emergency Medical Services (EMS) staff take the phone away from the resident and the caregiver then came and picked it up where EMS staff set it down. Based on interviews conducted 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 Facility staff left resident in urine-soaked clothing for an extended period of time. LPA Hurt conducted interviews with several witnesses who stated they observed residents in clothing that appeared to be soaked in urine for extended periods of time. Based on interviews conducted 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 Assistant Administrator, Airen Miro, and a copy of this report 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20230612142552
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 B
01/25/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
The following requirement has not been met as evidenced by:
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Licensee will put a plan place to be in compliance with regulation 87411(a), and copy will be sent to LPA by POC due date of 01/25/24.
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Facility staff frequently called local fire staff to assist with lifitng, and moving facility residents, which poses a potential, health, safety, or personal rights risk to residents in care.
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Request Denied
Type B
01/25/2024
Section Cited
CCR
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
The following requirement has not been met as evidenced by:
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Licensee will put a plan place to be in compliance with regulation 87468.1(a), and copy will be sent to LPA by POC due date of 01/25/24.
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Facility staff engaged in a verbal altercation with facility resident 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: 3 of 4
Control Number 24-AS-20230612142552
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)
Type A
01/11/2024
Section Cited
CCR
87265(b)(3)
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87265 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:87265 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence..
The following requirement has not been as evidenced by:
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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 01/11/2024.
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Based on interviews conducted facility residents are being left in urine soaked clothing for extended periods of time, which poses an immediate, health, safety, or personal rights risk to reisdents 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 4