<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 10/11/2023
Date Signed: 10/23/2023 11:46:14 AM

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
06/02/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230602110418
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: 56DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Tyler Barnes TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging resident medications
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 deliver findings on a complaint investigation. LPA met with facility Administrator Tyler Barnes and explained the purpose of today's visit.

Regarding the allegation staff are mismanaging a residents medications. LPA Hurt reviewed Centrally Stored Medication Logs, Medication Administration Records, and faxes to and from the Physician documenting all changes, and refusals of medications for Resident 1. There is no medications discontinued, or not given to Resident 1 without orders from a Physician. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff 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.
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: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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
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
06/02/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230602110418

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: 56DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Tyler Barnes TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not prevent altercations between residents
Staff do not inform residents authorized person of incidents occuring between residents
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 deliver findings on a complaint investigation. LPA met with facility Administrator Tyler Barnes and explained the purpose of today's visit.

Regarding the allegation Staff do not prevent altercations between residents. LPA Hurt reviewed facility records titled "Care Notes" for Resident 1. The Care notes document several incidents of inappropriate behaviors involving Resident 1 being aggressive with other facility residents. Based on interviews, and records reviewed during this investigation, 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: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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-20230602110418
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: MADONNA GARDENS
FACILITY NUMBER: 275202569
VISIT DATE: 10/11/2023
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...


Regarding the allegation Staff do not inform residents authorized person of incidents occurring between residents. LPA reviewed facility records titled "Care Notes" for Resident 1. The care notes document several incidents of Resident 1 being aggressive with other facility residents. The care notes do not document facility contacted Responsible Party of residents that were involved in altercations with Resident 1. Based on interviews, and records reviewed 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 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: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 24-AS-20230602110418
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: MADONNA GARDENS
FACILITY NUMBER: 275202569
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
87468.1(a)
1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Administrator will have Resident 1 re assesed immediately, and provide 1 on 1 care for Resident 1 to ensure the safety of other resients and submit proof to LPA Hurt by POC date of 10/12/2023.
8
9
10
11
12
13
14
Resident 1 has been in several alteractions with other facility residents which poses an immediate, health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
Under Appeal
Type B
10/25/2023
Section Cited
CCR
87468.1(a)(8)
1
2
3
4
5
6
7
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:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator will conduct training with facility staff on Reporting to Resident Responsible Parties and submit proof to State Licesning by 10/11/2023 POC date.
8
9
10
11
12
13
14
The facility did not document Responsible parties for several residents being notified after physical altercations Resident 1.
8
9
10
11
12
13
14
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: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4