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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206666
Report Date: 01/25/2022
Date Signed: 01/26/2022 08:21:17 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
01/20/2022 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20220120101228
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL VASSARFACILITY NUMBER:
547206666
ADMINISTRATOR:ENNIS,KRISTENFACILITY TYPE:
735
ADDRESS:4224 E VASSAR AVETELEPHONE:
(559) 622-8955
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:4CENSUS: 4DATE:
01/25/2022
UNANNOUNCEDTIME BEGAN:
07:32 AM
MET WITH:Administrator Kristin EnnisTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
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8
9
Staff are not following Covid-19 protocols
INVESTIGATION FINDINGS:
1
2
3
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5
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7
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9
10
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12
13
Licensing Program Analysts (LPA) Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA identified herself and explained the purpose of the visit and the elements of the allegations with Administrator Kristin Ennis via telephone. Administrator Kristin Ennis gave permission for Staff Zoraida Tavarez to sign for this report.


Based on LPA staff interviews, review of visitor and temperature logs,.observation of staff to be wearing masks and staff taking precautionary measures by utilizing covid protocols and testing regularly the allegation Staff are not following Covid-19 protocols 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 allegation is UNSUBSTANTIATED.

An exit interview was conducted with Staff Zoraida Tavarez and a copy of this report was provided to Administrator Krisitn Ennis via email.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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