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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 355202781
Report Date: 10/09/2024
Date Signed: 10/16/2024 06:43:20 PM

Substantiated


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
08/09/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240809101021
FACILITY NAME:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR:MITCHELL GUEVARAFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY:4CENSUS: 4DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Lead RBT, Maria RomanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff interacted inappropriately with a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/09/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility lead (RBT) registered behavioral technician Maria Roman and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care.

Allegation: Staff interacted inappropriately with a resident. Based on interviews and records review staff 1 (S1) spooked client from behind. This incident was investigated internally by facility office and S1 was found at fault. As a result, S1 was terminated on 08/07/2024. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D.

Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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 2
Control Number 24-AS-20240809101021
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: BAUTISTA HOME
FACILITY NUMBER: 355202781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
80072 Personal Rights (a) (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not observed as evidenced by:
1
2
3
4
5
6
7
Plan of correction was provided and deficiency was corrected by the visit day. Staff in-service training was provided to LPA by email.
8
9
10
11
12
13
14
The facility staff failed to follow Licensing regulation by providing dignity and respect to one out of four clients in care which poses potential health and safety risk to person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2