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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 355201055
Report Date: 04/27/2022
Date Signed: 04/27/2022 11:08:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/22/2022 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20220422145314
FACILITY NAME:WHISPERING PINES INN, LLCFACILITY NUMBER:
355201055
ADMINISTRATOR:PARK,CHARLES & MAEFACILITY TYPE:
740
ADDRESS:476 LOS VIBORAS ROADTELEPHONE:
(831) 636-9620
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:36CENSUS: 22DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Charles ParkTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff arent wearing face coverings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA identified herself and explained the purpose of the visit was investigate this compaint and to deliver findings Administrator Charles Park.

LPA toured the facility with the Administrator. LPA observed a staff to not be wearing mask. LPA reviewed records which shows the Administrator has a doctors note in place to not wear a mask.

Based on LPA's observations while touring the facility facility staff was observed to not be wearing a mask the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D.

Plan of correction and appeal rights was reviewed with Administrator.

An exit interview was conducted and a copy of this report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20220422145314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WHISPERING PINES INN, LLC
FACILITY NUMBER: 355201055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2022
Section Cited
CCR
87468.1(a)(2)
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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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Plan of Correction: POC LIcensee agrees to ensure all staff wear masks. POC was corrected during visit. Staff are now wearing masks.
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This requirement was not met as evidenced by:
Based on observation facility staff were not wearing masks, which poses a potential threat to the health, safety and personal rights risk of 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2