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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208929
Report Date: 12/29/2021
Date Signed: 12/29/2021 12:41:31 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
12/21/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211221155904
FACILITY NAME:GAITHER'S FAMILY HOME #3FACILITY NUMBER:
547208929
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1302 E CARMELO AVETELEPHONE:
(559) 687-0300
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 6DATE:
12/29/2021
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Adriene Smith, StaffTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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RSO who is not a client allegedly resides, is present or has contact that may pose a risk to the health and safety of clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Kamaldeep Kaur and Lady Cabrera conducted a complaint visit. Administrator Anna McDonald was unavailable and directed Staff Adriene Smith to sign this report.

10-day visit – Allegation: RSO who is not a client allegedly resides or has presence/contact that may pose a risk to the health and safety of the client(s) in care.

This agency has investigated the complaint alleging an RSO is residing at the facility or has presence/contact that may pose a risk to the health and safety of the client(s) in care at a facility licensed by the Department. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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