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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208825
Report Date: 10/21/2024
Date Signed: 10/31/2024 08:55:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
06/21/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240621134746
FACILITY NAME:PEOPLE'S CARE DAMSENFACILITY NUMBER:
547208825
ADMINISTRATOR:VIAYRA,MARIANAFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(559) 627-1281
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:4CENSUS: 0DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Mariana ViayraTIME COMPLETED:
11:21 AM
ALLEGATION(S):
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Unexplained fractures while in care
INVESTIGATION FINDINGS:
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13
This is an amended report.
On 10/30/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Eddie Rangel and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care.

Allegation: Unexplained fractures while in care. During complaint investigation department reviewed records and interviewed staff and witnesses. Based on interviews and records on 07/20/2023 C1 was taken to Medical Center (MC) and diagnosed with had a displaced Trimalleolar fracture of his left lower leg. Interviews revealed that client fall in a van, but there was no GER written for that incident.

Report continues on attached LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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 5
Control Number 24-AS-20240621134746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825
VISIT DATE: 10/21/2024
NARRATIVE
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On 11/19/2023, client (C1) went to Urgent Care, and he had a left tibial fracture from a fall on
11/16/2023 when he slipped in the shower. The staff interviewed stated C1 fell several times at the facility, but those incidents were not documented in a General Event Report (GER). The staff
were unable to provide specific dates or details of what caused C1 to fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted, report signed and copy of this report provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
06/21/2024 and conducted by Evaluator Vadim Gorban
COMPLAINT CONTROL NUMBER: 24-AS-20240621134746

FACILITY NAME:PEOPLE'S CARE DAMSENFACILITY NUMBER:
547208825
ADMINISTRATOR:VIAYRA,MARIANAFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(559) 627-1281
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:4CENSUS: 0DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Mariana ViayraTIME COMPLETED:
11:21 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff failed to seek immediate medical attention for client while in care
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
11
12
13
This is an amended report
On 10/30/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Eddie Rangel and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care.

Allegation: During complaint investigation department reviewed records and interviewed staff and witnesses. Based on interviews and records reviews client (C1) sustained two injuries on or about 7/20/2023 and 11/16/2023 in which staff were unable to recall what occurred and provided inconsistent statements and documentation. On 07/20/2023 C1 was taken to Medical Center (MC) and diagnosed with had a displaced Trimalleolar fracture of his left lower leg. Interviews revealed that client fall in a van, but there was no GER written for that incident

Report continues on attached LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240621134746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825
VISIT DATE: 10/21/2024
NARRATIVE
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C1 had a fall on 11/16/2023, but he was not taken to Urgent Care until 11/19/2023. He was then directed to the ED. He was not taken to the ED until 11/20/2023 and it was discovered he had a left fibular fracture. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D

Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240621134746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2024
Section Cited
CCR
80065(f)(3)
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80065 Personnel Requirements (3) Provision of client care and supervision, including communication.This requirement was not observed aas evidenced by:
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The facility administrator offered provide to Licensing department staff training on patient care when and how to seek medical attention by POC due date to LPA by email.
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The facility failed to demonstrate on- the-job kowledge and skills by responding to event to take client to medical profesionals and providing care and supervision on teh day of the incident. Which poses immedate health safety risk to persons in care.
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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: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5