547203298-5-3-2023-24-AS-SPIY-CV9R9M-20230901124945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547203298
Report Date: 05/03/2023
Date Signed: 05/03/2023 03:56:30 PM

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
05/02/2023 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230502101036

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:	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Tony Ong		TIME COMPLETED:	04:12 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) L. Xiong conducted the subsequent complaint investigation visit to the facility. I met with Administrator, Tony Ong and informed him the purpose of the visit.
During the course of this complaint investigation LPA interviewed staff on duty and obtained facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility was refusing to pickup R1 from the hospital when hospital was discharging R1. R1 went to the hospital for a medical condition and is still resident of the facility. When R1 is discharge from the hospital, it's the facility's responsibility to bring R1 back to the facility. Based on LPAs observations and interviews and records, the preponderance of evidence standard has been met, therefore the above allegation 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: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230502101036

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: 05/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/02/1987 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 (a) Eviction Procedures; The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. LPA observed from the interviews R1's needs did changed and the facility is not able to continue to meet R1's needs, however, at this time the facility fail to give R1 and R1's responsible party the proper eviction notice.	1 2 3 4 5 6 7	Per Administrator, will bring R1 back to the facility and start the proper eviction notice and help R1's case manager look for a new facility that is able to meet R1's needs to move to.
	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: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
05/02/2023 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230502101036

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:	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Tony Ong		TIME COMPLETED:	04:12 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff abandoned resident

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 abandoned resident. 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: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 3