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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208243
Report Date: 05/23/2022
Date Signed: 05/23/2022 08:54:41 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
01/31/2022 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20220131164536
FACILITY NAME:ENCLAVE AT THE FOOTHILLSFACILITY NUMBER:
547208243
ADMINISTRATOR:PEREZ, KRISTINAFACILITY TYPE:
735
ADDRESS:10650 ROAD 256TELEPHONE:
(559) 527-5090
CITY:TERRA BELLASTATE: CAZIP CODE:
93270
CAPACITY:20CENSUS: 17DATE:
05/23/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Assistant Administrator (AA) Javier Hernandez; Residential Site Supervisor (RSS) Michelle Garcia; TIME COMPLETED:
09:00 PM
ALLEGATION(S):
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Unqualified staff providing medication to residents.
INVESTIGATION FINDINGS:
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An unannounced visit was conducted on the dates & during the times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Assistant Administrator (AA) Javier Hernandez & Residential Site Supervisor (RSS) Michelle Garcia.

The above allegation has been investigated by the Department. Based on discussion with AA & staff training records the Department has found the allegation to be substantiated

Deficiency issued.
Exit interview conducted with AA & RSS. Records provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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
Control Number 24-AS-20220131164536
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: ENCLAVE AT THE FOOTHILLS
FACILITY NUMBER: 547208243
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2022
Section Cited
CCR
80065(f)(4)
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Personnel Requirements - All personnel shall be given on-the-job training ... Assistance with prescribed medications which are self-administered.
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AA has agreed to submit facility medication training plan & commitment to training by due date.
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Staff assisted with medication without required medication training.
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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: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3