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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206600
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:52:14 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
06/12/2024 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20240612110524
FACILITY NAME:WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #1FACILITY NUMBER:
547206600
ADMINISTRATOR:GARCIA, BRIANNAFACILITY TYPE:
735
ADDRESS:25401 ROAD 152TELEPHONE:
(559) 747-3319
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:6CENSUS: 4DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Administrator Tiffany JohnsonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not notify CCL of relocation of residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent complaint visit. LPA met with Administrator Tiffany Johnson and Tami Levyva and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on interviews conducted and records reviewed the facility did not report the incident in a timely manner.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator, a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 2
Control Number 24-AS-20240612110524
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: WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #1
FACILITY NUMBER: 547206600
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
80061(b)(E)
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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

This requirement was not met evident by:
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LPA reviewed a written incident report that was submitted on 6/14/2024 which is outside the required 7 days. Based on interviews and records review facility failed to report on the next working business day of the incident.
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Licensee and Staff agrees to conduct an in-service training to review reporting requirements Title 22, Division 6
Chapter 1 Regulation 80061. Licensee to submit a statement of understanding of requirements by due date.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2