547203298-2-13-2025-24-AS-AWAN-DE7UEV-20250224143146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547203298
Report Date: 04/12/2024
Date Signed: 02/13/2025 09:31:59 AM

Unfounded

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
03/22/2024 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240322111022

FACILITY NAME:	AUTUMN OAKS		FACILITY NUMBER:	547203298
ADMINISTRATOR:	ONG, ANTONIO G.		FACILITY TYPE:	740
ADDRESS:	848 N. JAYE STREET		TELEPHONE:	(559) 784-4144
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY:	44	CENSUS: 24	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Lisa Ong		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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Staff did not keep facility free from insects.
Facility owner placed a pad lock on the freezer.

INVESTIGATION FINDINGS:

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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: Staff did not keep facility free from insects, and Facility owner placed a pad lock on the freezer are UNFOUNDED. The evidence from the investigation indicated the facility has monthly contract with Sierra Vista Exterminator to treat facility for all pests and the pad lock is for the additional freezer and the freeze use daily by the facility cook was not locked. In addition, the cook has the key for the pad lock. This agency has investigated the complaint alleging (Staff did not keep facility free from insects, and Facility owner placed a pad lock on the freezer). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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 4

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
03/22/2024 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240322111022

FACILITY NAME:	AUTUMN OAKS		FACILITY NUMBER:	547203298
ADMINISTRATOR:	ONG, ANTONIO G.		FACILITY TYPE:	740
ADDRESS:	848 N. JAYE STREET		TELEPHONE:	(559) 784-4144
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY:	44	CENSUS: 24	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Lisa Ong		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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Staff are not ensuring that residents have clean bedding.

INVESTIGATION FINDINGS:

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During this visit LPA delivered investigation findings regarding the above allegations.The Department has investigated the complaint alleging: Staff are not ensuring that residents have clean bedding. Based on the interviews conducted and/or records review the above allegation is 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: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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 4

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
03/22/2024 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240322111022

FACILITY NAME:	AUTUMN OAKS		FACILITY NUMBER:	547203298
ADMINISTRATOR:	ONG, ANTONIO G.		FACILITY TYPE:	740
ADDRESS:	848 N. JAYE STREET		TELEPHONE:	(559) 784-4144
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY:	44	CENSUS: 24	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Lisa Ong		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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Facility is storing expired food.

INVESTIGATION FINDINGS:

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During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. During the investigation LPA did observed expired bread and staff did observed two expired can goods. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 24-AS-20240322111022

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: AUTUMN OAKS	FACILITY NUMBER: 547203298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/15/2024 Section Cited CCR 87555(8)	1 2 3 4 5 6 7	87555 General Food Service Requirements LPA observed bread expired.	1 2 3 4 5 6 7	The expired food were thrown out. No further correction needed.
	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
	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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

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