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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547203298
Report Date: 02/28/2024
Date Signed: 04/16/2024 07:40:44 PM

Unsubstantiated


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
11/13/2023 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231113120634
FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:44CENSUS: DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Matilde GarciaTIME COMPLETED:
08:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense medication as prescribed.
The resident’s room is malodorous.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Staff did not dispense medication as prescribed. The resident’s room is malodorous. Based on the interviews conducted and/or records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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
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
11/13/2023 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231113120634

FACILITY NAME:AUTUMN OAKSFACILITY NUMBER:
547203298
ADMINISTRATOR:ONG, ANTONIO G.FACILITY TYPE:
740
ADDRESS:848 N. JAYE STREETTELEPHONE:
(559) 784-4144
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:44CENSUS: DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Matilde GarciaTIME COMPLETED:
08:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not assisting the resident with medical appointments.
Facility does not ensure equipment is in good repair.
Staff do not clean residents' rooms.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
1. Licensing Program Analyst (LPA) L Xiong conducted the complaint investigation visit to the facility.
During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Facility staff are not assisting the resident with medical appointments, Facility does not ensure equipment is in good repair, and Staff do not clean residents' rooms are UNFOUNDED. The evidence from the investigation indicated facility staff did assist with arranging and transporting resident to medical appointments, Resident is ambulatory and does not use or need wheelchair, and residents' rooms are cleaned multiple times daily. This agency has investigated the complaint alleging (Facility staff are not assisting the resident with medical appointments, Facility does not ensure equipment is in good repair, and Staff do not clean residents' rooms). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2