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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209295
Report Date: 07/03/2024
Date Signed: 07/18/2024 12:48:29 PM

Unsubstantiated


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
02/16/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240216110501
FACILITY NAME:PROVIDENT HEALTH CARE TAMARACKFACILITY NUMBER:
247209295
ADMINISTRATOR:TIU, JERRYFACILITY TYPE:
735
ADDRESS:1390 5TH STREETTELEPHONE:
(209) 388-1002
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 4DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Maria SimonTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not follow resident's special diet
Due to lack of supervision, resident left facility
Staff did not return resident's medication when the resident left the facility
Staff are not properly trained to deal with behaviors of residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on at July 3, 2024 at 12:30 p.m. to deliver findings on the above allegations. LPA met with facility Administrator, Maria Simon and explained the purpose for today’s visit.

Regarding the allegation Staff did not follow resident's special diet. Resident 1 did have Physician's Orders for "dietary restrictions" listing suggested meals, and foods to avoid. Facility staff did offer the suggested food items, and prompt Resident 1 to eat the suggested diet. Resident 1 however did not always want to eat the suggested foods, and avoid specific foods listed on the Physician's orders. Resident 1 is an unconserved adult with personal rights to choose the foods they consume. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Continued....


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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
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
02/16/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240216110501

FACILITY NAME:PROVIDENT HEALTH CARE TAMARACKFACILITY NUMBER:
247209295
ADMINISTRATOR:TIU, JERRYFACILITY TYPE:
735
ADDRESS:1390 5TH STREETTELEPHONE:
(209) 388-1002
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Maria SimonTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff refused to pick up resident from school
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 07/03/2024 at 12:30 p.m. to deliver findings on the above allegations. LPA met with facility Administrator, Maria Simon and explained the purpose for today’s visit.

Regarding the allegation staff refused to pick up resident from school. Reporting Party stated Client 1 was not picked up from day program. Licensee was aware Client 1 needed a ride home from day program and failed to provide transporation. Central Valley Regional center was made aware of this incident and provided counsel to the facility on basic services. The speciifc date of incident was not provided throughout the course of this investigation. Based on interviews conducted 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 facility Administrator, Maria Simon, and copy of this report along with appeals rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20240216110501
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: PROVIDENT HEALTH CARE TAMARACK
FACILITY NUMBER: 247209295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
80068(a)(1)(c)
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80068 Admission Agreements(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.(1) Prior to admitting a developmentally disabled adult recommended by a Regional Center, the licensee of an ARF shall obtain from the Regional Center written certification which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803.(c) Admission agreements must specify the following:(1) Basic services. The following requirement has not been met as evidenced by:
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Administrator Maria will submit written plan to avoid any residents not being provided transportation in the future and submit to LPA by POC date of 07/18/2024.
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 The facilities admission agreement documents under "Basic Services" transportation is to be provided for client to socialization activities, Resident 1 was not provided transportation from day program , 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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240216110501
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: PROVIDENT HEALTH CARE TAMARACK
FACILITY NUMBER: 247209295
VISIT DATE: 07/03/2024
NARRATIVE
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Regarding the allegation. Due to lack of supervision, resident left facility. Resident 1 was provided 1 on 1 supervision due to behaviors displayed at the facility. The 1 on 1 staff was present at the facility when the AWOL on 10/15/2023 took place. Facility staff followed the necessary protocol required when a resident AWOL’s from the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff did not return resident's medication when the resident left the facility. Reporting Party stated after Resident 1 left the facility staff did not return all medications. Facility staff stated they did not have the medication in question as not returned to Reporting party as it was still at the local pharmacy. Witnesses interviewed stated they do not believe any medication was deliberately withheld by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff are not properly trained to deal with behaviors of residents. LPA Hurt reviewed the facilities program plan documenting required staff training. The facility staff is sufficiently trained to deal with the behaviors of residents that are to be admitted into this facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with facility Administrator, Maria Simon, and copy of this report rights provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4