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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206666
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:59:38 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
09/30/2021 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20210930110028
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL VASSARFACILITY NUMBER:
547206666
ADMINISTRATOR:MAGANA, NORALBAFACILITY TYPE:
735
ADDRESS:4224 E VASSAR AVETELEPHONE:
(559) 622-8955
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:4CENSUS: 4DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kristin Ennis, AdministratorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff are not isolating COVID (+) residents.
INVESTIGATION FINDINGS:
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During the course of the investigation, LPAs Mai Yang and David Ayers conducted virtual tour of the facility due to facility having clients who were COVID-19 positive at the time. LPA’s observed that facility was not following COVID-19 health and safety precautions when they were allowing 3 of 4 COVID positive clients to cohort with 1 of 4 COVID-19 negative clients. In addition, staff were not wearing surgical masks.
Based on LPAs observation, the preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, Section 80072(a)(2) is being cited on the attached LIC9099D. Appeal rights provided and exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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-20210930110028
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: KAISER SPECIALIZED RESIDENTIAL VASSAR
FACILITY NUMBER: 547206666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2021
Section Cited
CCR
80072(a)(2)
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80072(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Administrator will submit to CCL a proof of staff retrained on COVID infection control practices and revised infection control protocols by due date.
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Based on observation and interview the Licensee failed to isolate clients, allowing 3 out of 4 residents with positive COVID-19 to cohort with negative client. LPA observed staff not wearing all of the required personal protective equipment as required.
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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: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
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