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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 540405657
Report Date: 02/03/2022
Date Signed: 02/14/2022 10:20:06 AM



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
02/18/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210218112424
FACILITY NAME:CASA GRANDE SENIOR CARE HOME #2FACILITY NUMBER:
540405657
ADMINISTRATOR:SILVEIRA, JOE & MARIAFACILITY TYPE:
740
ADDRESS:417 E. WALNUT AVETELEPHONE:
(559) 733-0233
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:46CENSUS: 30DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Adminsitrator, Lisa SilveiraTIME COMPLETED:
05:07 PM
ALLEGATION(S):
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Staff prevented resident from being seen by hospice nurse
INVESTIGATION FINDINGS:
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On 2/3/2022 Licensing Program Analyst M. Garza completed a complaint visit for the above allegations. Due to COVID precautionary measures the visit was completed via tele-conference. LPA explained reason for video call and tour the facility with Administrator. LPA observed residents in rooms.

During the course of the investigation LPA conducted interviews and reviewed records (Personnel Report, staff schedule, visition guidelines and current PIN's). Interviews revealed facility was not allowing visitors (including hospice and family). Through LPA observation, facility observed signage posted "No visitors". PIN's did not reflect restrictions of visitors during this time. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation above is found to be SUBSTANTIATED. A deficiency is being cited, see attached 9099D. Exit interview conducted. Plan of Correction was reviewed and developed with Administrator. A copy of this report, deficiency and appeal rights were discussed and provided via email. A delivered and read receipt serves as confirmation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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-20210218112424
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: CASA GRANDE SENIOR CARE HOME #2
FACILITY NUMBER: 540405657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2022
Section Cited
CCR
87468.2(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Adminsitrator to complete training with staff on personal rights, review current PIN's by POC date. Administrator to contact RO with any questions regarding visors/personal rights.
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This requirement was not met as evidence by: LPA observation of "No Visitors Allowed" sign at front door and through LPA interview with staff. Staff confirmed no visitor (including hospice) were allowed.
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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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
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