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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 02/06/2023
Date Signed: 02/07/2023 11:24:32 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
01/31/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230131093230
FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:PATRICIA KINGFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 48DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Tyler BarnesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
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7
8
9
Staff caused a resident to fall multiple times while in care
Staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA Hurt met with facility Executive Director Tyler Barnes and explained the purpose of today's visit.

Regarding the allegation Staff caused a resident to fall multiple times while in care. LPA Hurt reviewed document titled "Internal Incident Report" dated 01/07/2023 documenting Resident 1 was found on the floor of his apartment around 8:40 a.m. on right side of his body. Administrator Tyler Barnes stated this is the only fall Resident 1 had since being at the facility. LPA Hurt interviewed Resident 1's Power of Attorney who stated Resident 1 had one fall at the facility since he has been there, and they were immediately notified. Based on facility records reviewed, and interviews conducted this allegation is UNSUBSTANTIATED. 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 on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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 4
Control Number 24-AS-20230131093230
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: MADONNA GARDENS
FACILITY NUMBER: 275202569
VISIT DATE: 02/06/2023
NARRATIVE
1
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14
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32
...Continued from 9099

Regarding the allegation Staff are not properly trained. LPA Hurt reviewed records documenting facility staff is given training on two person resident transfers by the facility nurse. Administrator Tyler Barnes stated the facility nurse also does random hands on In - Service Training's focusing on any areas needed during staff shift changes. Administrator Tyler Barnes stated during facility all staff meetings hospice services also provides training to staff on different subjects related to resident care.Based on facility records reviewed, and interviews conducted this allegation is UNSUBSTANTIATED. 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 Tyler Barnes, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
01/31/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230131093230

FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:PATRICIA KINGFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 48DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Tyler BarnesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are following a resident's medication orders
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA Hurt met with facility Executive Director Tyler Barnes and explained the purpose of today's visit.

Regarding the allegation Staff are not following a resident's medication orders. LPA Hurt reviewed "Physician's Orders" for Resident 1 documenting medication Hydrocodone/Apap 5/2325 to be taken as needed for pain prescribed on October 3, 2022. Resident 1's Physicians Report documents he is unable to make decisions related to his care at this time, but can communicate needs at times. LPA Hurt spoke with Resident 1's medical Power of Attorney who stated they are aware the facility staff is giving him pain medications as prescribed, and they have no problem with it.This agency has investigated the complaint alleging facility staff are not following a residents medication orders. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.”)

Continued on 9099C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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-20230131093230
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: MADONNA GARDENS
FACILITY NUMBER: 275202569
VISIT DATE: 02/06/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 9099



No Deficiencies are being cited Per Title 22 Regulations.

Exit Interview Conducted with facility Administrator Tyler Barnes, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4