547206599-8-12-2022-24-AS-MHON-CHCM8E-20220816092300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547206599
Report Date: 08/12/2022
Date Signed: 08/12/2022 09:48:06 AM

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
04/29/2022 and conducted by Evaluator Melinda Medina

COMPLAINT CONTROL NUMBER: 24-AS-20220429082440

FACILITY NAME:	WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #2		FACILITY NUMBER:	547206599
ADMINISTRATOR:	JOHNSON, TIFFANY L		FACILITY TYPE:	735
ADDRESS:	20222 AVE 332		TELEPHONE:	(559) 564-0295
CITY:	WOODLAKE	STATE: CA	ZIP CODE:	93286
CAPACITY:	4	CENSUS: 4	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:	Tiffany Johnson		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Client sustained bruises as the result of being shoved

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) M. Medina conducted a subsequent visit to facility to deliver findings to complaint. LPA identified herself and discussed the purpose of visit with Administrator, Tiffany Johnson.

LPA conducted interviews, and reviewed documentation received during complaint investigation. Based on interviews, and record reviews, there was insufficient evidence that client sustained bruises as the result of being shoved.

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.

Exit interview conducted. No deficiencies cited.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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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