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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547203448
Report Date: 01/25/2023
Date Signed: 01/25/2023 04:25:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
11/14/2022 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221114142745
FACILITY NAME:JORDETH SENIOR CARE HOMEFACILITY NUMBER:
547203448
ADMINISTRATOR:CIANO CODANGOSFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:5CENSUS: 5DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Davilyn Mancilla, Licensee/AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff confined resident to their room.
INVESTIGATION FINDINGS:
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On 1/25/23 at 1:45 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection and was granted entry by Licensee/Administrator (LIC) Davilyn Mancilla.

LPA interviewed LIC. During the investigation, LPA reviewed records and conducted interviews. LPA found that facility staff confined resident to their room. LIC stated a plastic door knob cover was placed on the inside door knob of R1's bedroom to prevent R1 from leaving the facility after R1 AWOL'd the second time from the facility. Therefore, the above allegation is substantiated.

A deficiency is being cited based on LPA interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D. Exit interview conducted and a Plan of Correction was developed with Licensee. A copy of this report and appeal rights were given to Licensee, whose signature confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
11/14/2022 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221114142745

FACILITY NAME:JORDETH SENIOR CARE HOMEFACILITY NUMBER:
547203448
ADMINISTRATOR:CIANO CODANGOSFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:5CENSUS: 5DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Davilyn Mancilla, Licensee/AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Facility staff denied resident access the TV and/or remote.
Facility staff did not ensure that resident received medication on a regular basis.
Facility staff did not assist resident with activities of daily living (unattended and not toileted).
INVESTIGATION FINDINGS:
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On 1/25/23 at 1:45 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection and was granted entry by Licensee/Administrator (LIC) Davilyn Mancilla.

LPA interviewed LIC. During the investigation, LPA conducted interviews and reviewed records. Based on LPA’s interviews and records reviewed, there was not sufficient evidence to show facility staff denied resident access to the TV and/or remote, facility staff did not ensure that resident received medication on a regular basis, or that facility staff did not assist with activities of daily living. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. A copy of this report was given to Licensee, whose signature confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 3
Control Number 24-AS-20221114142745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: JORDETH SENIOR CARE HOME
FACILITY NUMBER: 547203448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
This requirement is not met as evidenced by:
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Licensee will submit proof of written statement about non-use of door knob covers, to CCL by POC due date.
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LPA found that facility staff confined resident to their room. LIC stated a plastic door knob cover was placed on the inside door knob of R1's bedroom to prevent R1 from leaving the facility after R1 AWOL'd the second time from the facility. This poses a potential safety or personal rights risk to residents in care.
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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) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3