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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547202809
Report Date: 07/17/2024
Date Signed: 07/19/2024 09:40:43 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
06/26/2024 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20240626124959
FACILITY NAME:TRANSITIONAL LIVING CENTERFACILITY NUMBER:
547202809
ADMINISTRATOR:LEIGH (CABEJE), TAMARAFACILITY TYPE:
735
ADDRESS:546 E. TULARE AVENUETELEPHONE:
(559) 733-6648
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:38CENSUS: DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Interim Administrator (IAdmin) Phillip Delgado by telephone; Mental Health Program Manager II (MHPM II) Rosie Ruiz (Maduena);TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not report incidents to appropriate parties.

INVESTIGATION FINDINGS:
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A Complaint visit was conducted by Licensing Program Analyst (LPA) K. Mcclurg met with Mental Health Program Manager II (MHPM II) Rosie Ruiz (Maduena) & stated purpose of visit, & was allowed to proceed. LPA called & spoke with Interim Administrator (IAdmin) Phillip Delgado by telephone & stated purpose of visit. IAdmin not available to join LPA during visit. MHPM II authorized to sign for receipt of report(s).

LPA inquired of IAdmin about submission of complete reports regarding incidents. It was determined that Reporting Requirements were not met. The Department was not notified as required for 5 known incidents, including a death. Five (5) known incident written reports were not submitted to the Department including 1 client-on-client altercation, 3 missed medications, & 1 Death Report. One separate incident report was received 4 weeks beyond required submission time period. Late report requires correction. The late report along with a current report are incomplete, missing specific required information, including all names of persons, clients, & staff involved, notified, followed up with.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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 3
Control Number 24-AS-20240626124959
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: TRANSITIONAL LIVING CENTER
FACILITY NUMBER: 547202809
VISIT DATE: 07/17/2024
NARRATIVE
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Continued.

The Department has investigated the above allegation & determined it to be Substantiated.

Deficiency issued.
Exit interview conducted with MHPM II. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240626124959
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: TRANSITIONAL LIVING CENTER
FACILITY NUMBER: 547202809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2024
Section Cited
CCR
80061(b)
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Reporting Requirements. Upon the occurrence...of any...events specified---a report shall be made to the licensing agency within the agency's next working day during its normal business hours...(&)Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event...a written report containing...information specified...shall be submitted... within seven days following the occurrence of...event.
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The Interim Administrator has agreed to complete 2 of 2 submitted reports, & 5 known incident written reports including 1 client-on-client altercation, 3 missed medications, & 1 Death Report.
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For 5 known incidents, including a death, the Department was not notified, & written report not submitted, or submitted 4+ weeks beyond time frame.
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All reports to be corrected, created, & submitted to LPA prior to due date.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC9099 (FAS) - (06/04)
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