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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206651
Report Date: 05/05/2022
Date Signed: 05/05/2022 01:35:24 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
08/03/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210803102158
FACILITY NAME:EWING PALM HOME, LLCFACILITY NUMBER:
547206651
ADMINISTRATOR:EWING, ELIZABETH G.FACILITY TYPE:
735
ADDRESS:4836 W. JAMES CTTELEPHONE:
(559) 429-4856
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:6CENSUS: DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Licensee, Elizabeth EwingTIME COMPLETED:
01:53 PM
ALLEGATION(S):
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Staff conduct poses a risk to clients
INVESTIGATION FINDINGS:
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On 5/5/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver complaint findings. LPA met with Licensee, Elizabeth Ewing and informed reason for visit. LPA was COVID pre-screened upon entry. Residents at day program and in the community at time of visit.

During investigation documents received, interview(s) completed. During interviews it was disclosed that staff at the facility had a verbal altercation in front of residents in care.

The allegation listed above is SUBSTANTIATED. Per Title 22, the following deficiencies are being cited on the attached 9099D. Plan of correction discussed. Appeal rights given. Exit interview completed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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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Control Number 24-AS-20210803102158
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: EWING PALM HOME, LLC
FACILITY NUMBER: 547206651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Per Licensee personal discussions/disagreements will be discussed elsewhere. Cooling off times will be given. Licensee/staff to complete training on personal rights of residents. Sign in sheet and training material to be provided to CCL by POC date.
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This requierment was not met as evidence by: LPA interview(s). During interviews it was disclosed that staff at the facility had a verbal altercation in front of residents in care. This posses a potential Health and Safety 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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
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