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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206290
Report Date: 12/11/2024
Date Signed: 02/12/2025 02:48:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
08/26/2024 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240826093117
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL TAYLORFACILITY NUMBER:
547206290
ADMINISTRATOR:CARPENTER,EMILYFACILITY TYPE:
735
ADDRESS:2816 W TAYLOR AVETELEPHONE:
(559) 636-2590
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:4CENSUS: 3DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Emily CarpenterTIME COMPLETED:
02:07 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruising.
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.

Interviews and record review revealed that R1 was admitted to the hospital due to an “increase in weakness and tremors”. Consistent statements from facility staff revealed that staff did not “notice any bruising on R1’s body” prior to R1 being sent to the hospital. Medical records indicated that R1 sustained bruising to the body prior to being admitted to the hospital; however, the bruising could have been caused by R1’s “uncontrolled movements and tremors”.

The Department has investigated the complaint alleging: Resident sustained unexplained bruising. 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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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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