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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202260
Report Date: 08/29/2023
Date Signed: 08/30/2023 09:49:02 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
04/07/2023 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20230407155801
FACILITY NAME:ARCHWAY OF CARMELFACILITY NUMBER:
275202260
ADMINISTRATOR:CYRIL TUPINOFACILITY TYPE:
740
ADDRESS:3262 TAYLOR ROADTELEPHONE:
(831) 269-4164
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 6DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Maria Carrillo-CaregiverTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not properly manage resident's incontinence care resulting in infections.
Staff did not seek timely medical care for resident.
Staff did not ensure that resident received their medication in a timely manner.
Staff did not put appropriate measures into place for a resident who was a fall risk.
Staff did not inform resident's responsible person of resident's incidents.
Staff handled resident in a rough manner.
Staff did not respond to resident’s requests for assistance in a timely manner.
Staff did not assist resident with their hygiene needs in a timely manner.
INVESTIGATION FINDINGS:
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On 8/29/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with caregiver Maria and contacted Licensee Cyril Tupino. The purpose of this visit is to deliver the finding of the investigation completed by the Department. Licensee granted permission for staff to sign this report on his behalf. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

During the course of the investigation, the department inspected the facility, conducted interviews, and reviewed records. Resident 1(R1) was admitted to the facility on 12/22/2022. R1 developed a unirary tract infection on 3/24/2023. Facility staff requested the hospice agency order medications to treat the infection that same day. R1 fell from their wheelchair on 3/24/2023: R1's responsible party was informed of the incident on 3/25/2023. According to statements from witnesses who did not work for the facility, R1's hygeine needs were being met and staff were properly managing their incontinence care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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-20230407155801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ARCHWAY OF CARMEL
FACILITY NUMBER: 275202260
VISIT DATE: 08/29/2023
NARRATIVE
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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 allegations are found to be unsubstantiated at this time. Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2