547209005-8-16-2023-24-AS-MHON-CVELSJ-20230906090049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547209005
Report Date: 08/15/2023
Date Signed: 08/16/2023 06:13:12 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
08/09/2023 and conducted by Evaluator Malia Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230809155515

FACILITY NAME:	MARTINEZ RESIDENCE		FACILITY NUMBER:	547209005
ADMINISTRATOR:	MARTINEZ, EESAENG		FACILITY TYPE:	735
ADDRESS:	3527 W OAKRIDGE AVE		TELEPHONE:	(559) 608-5188
CITY:	VISALIA	STATE: CA	ZIP CODE:	93291
CAPACITY:	4	CENSUS: 4	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Eesaeng Martinez, Licensee/Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff did not meet resident's needs resulting in injury.

INVESTIGATION FINDINGS:

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On 8/15/23 at 1:52 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Eesaeng Martinez arrived a short time later.

LPA reviewed records, made observations, and conducted interviews. Based on records reviewed, observations, and interviews conducted, there was not sufficient evidence to show the facility staff did not meet the resident's needs resulting in injury. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the above allegation is unsubstantiated.

Exit interview was conducted. A copy of this report was given to Licensee, whose signature confirms receipt of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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