547208261-9-16-2020-24-AS-AXIG-BTNKKW-20200921075859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547208261
Report Date: 09/16/2020
Date Signed: 09/16/2020 02:37:27 PM

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
03/13/2020 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20200313165745

FACILITY NAME:	TLC ASSISTED LIVING FOR SENIORS		FACILITY NUMBER:	547208261
ADMINISTRATOR:	COSTA, LORETTA M.		FACILITY TYPE:	740
ADDRESS:	2530 S BEN MADDOX WAY		TELEPHONE:	(559) 627-5684
CITY:	VISALIA	STATE: CA	ZIP CODE:	93292
CAPACITY:	26	CENSUS:	DATE:	09/16/2020
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Assistant Administrator Brian Costa		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility overcharged resident.
Staff did not change resident's clothing.
Staff refused to administer medication to resident.

INVESTIGATION FINDINGS:

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Consistent with federal guidelines and Executive Order issued by Governor Gavin Newsom to improve infection control and prevent the transmission of COVID-19 to our most vulnerable and high-risk residents, the Department conducted this inspection by phone.

On this date Licensing Program Analyst (LPA) K. Mcclurg conducted a Complaint tele-visit with Assistant Administrator Brian Costa.

Continued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

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 2

Control Number 24-AS-20200313165745

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: TLC ASSISTED LIVING FOR SENIORS	FACILITY NUMBER: 547208261
	VISIT DATE: 09/16/2020

NARRATIVE

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Continued from Page 1.

Allegation reviewed. Interviews conducted. Records reviewed. Facility records show signatures for fees charged. Staff denies that clothing was not changed. Facility records indicate delay in Dr. Order for PRN medication. According to staff, resident did not request or indicate need for PRN.

The Department has investigated the allegations & determined that they are unsubstantiated.

Exit interview conducted with Assistant Administrator Brian Costa. Report provided.

End of Report.

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC9099 (FAS) - (06/04)

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