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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547206666
Report Date: 03/07/2022
Date Signed: 03/07/2022 05:35:39 PM

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
04/14/2021 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20210414141203
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:
03/07/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Kristin EnnisTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff is not meeting the needs of the resident.
INVESTIGATION FINDINGS:
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An unannouced Complaint visit was conducted by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Administrator (Admin) Kristen Ennis;. LPA stated purpose of visit.

The Department has investigated the above allegation. Based on available information, the allegation has been determined to be unsubstantiated.

Exit interview conducted with Admin. Report(s) provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
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 3
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
04/14/2021 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20210414141203

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:
03/07/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Kristin EnnisTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff yells and speaks inappropriately to resident.
Staff hides resident's clothing and takes away the resident's clothing.
INVESTIGATION FINDINGS:
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The Department has investigated the above allegations. Based on available information is was determined that staff did speak inappropriately & woult withhold/take clients item. The allegations have been substanitated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20210414141203
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: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited
CCR
80072(a)(1)
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Personal Rights. "...each client shall have personal rights which include, but are not limited to, the following:
To be accorded dignity in
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The Administrator stated that they will submit paperwork showing final outcome regarding S1 by due date.
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his/her personal relationships with staff and other persons.
S1 spoke inappropriately to clients & hid C1's clothing/personal belongings.
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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: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3