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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 06/13/2024
Date Signed: 06/18/2024 09:40:25 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
05/20/2024 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20240520102606
FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:TYLER BRANESFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 56DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adminsitrator, Renee HamiltonTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not give resident medication as prescribed
Staff are not following reporting requirements
Staff undressed residents in the common area in front of visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on June 13,2024 at 10:00 a.m. to investigate the above allegations. LPA met with facility Adminstrator Renee Hamilton, and explained the purpose for today’s visit.

Regarding the allegation Staff did not give resident medication as prescribed. LPA Hurt observed a physician speaking with Administrator about Resident 1 has not a specific medication for over a month. The physician stated the facility staff has been faxing the wrong number for refills. Based on records reviewed, and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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-20240520102606
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: 06/13/2024
NARRATIVE
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Continued..

Regarding the allegation Staff are not following reporting requirements. LPA Hurt reviewed Madonna Gardens facility online file, and there are no reports from the facility for 12/2023. LPA Hurt reviewed facility care notes for Resident 1 , documenting Resident 1 fell and was transported to the local hospital. This incident was not reported to State Licensing. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff undressed residents in the common area in front of visitors. LPA Hurt interviewed two facility staff who both stated on 05/18/24 facility Staff 1 requested female Resident 2 to lift the back of her shirt up past her undergarments to conduct a skin check in front of other facility residents, and visitors. Facility staff did not provide skin check sheets from 05/18/24 for review. Based on LPA 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, and a copy of this report provided.
Exit interview conducted with facility Administrator Renee Hamilton, and copy of report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20240520102606
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
87211(a)
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87211(a)Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
The following requirement has not been met as evidenced by:
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Administrator will conduct staff training on Reporting Requirements, and send proof to LPA by POC date of 06/27/24
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Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential, health, safety, or personal rights risk to residents in care.
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Type B
06/27/2024
Section Cited
CCR
87468.1(a)(1)
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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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Administrator will conduct staff training on Personal rights of residents, and send proof to LPA by POC date of 06/27/2024.
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Staff 1 exposed Resident 2's skin in a facility common area in front of other residents, and visitors. which poses
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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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240520102606
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:
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Administrator will conduct staff training on medication administration, and provide proof to LPA by POC date of 06/14/2024.
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Resident 1 was not provided prescribed medication for more than a month, which poses an immediate, health, safety, or personal rights risk to residents in care.
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Type A
CCR
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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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4