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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209130
Report Date: 06/29/2023
Date Signed: 06/29/2023 08:19:00 AM

Unsubstantiated


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
04/11/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230411152417
FACILITY NAME:BAXTER-LEYVA ADULT FACILITY, LLCFACILITY NUMBER:
547209130
ADMINISTRATOR:LEYVA, KRISTYNFACILITY TYPE:
735
ADDRESS:2230 W. PUTNAM COURTTELEPHONE:
(559) 310-7357
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 6DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Administrator Kristyn LeyvaTIME COMPLETED:
08:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint inspection to deliver findings. LPA explained reason for inspection and was granted entry by Administrator Kristyn Leyva.

LPA conducted interviews and reviewed C1's file. C1 has behaviors that could have caused injury and it was unable to be determined how or where the client obtained the injury.

Based on interviews, it is undermined if a Resident sustained unexplained injury while in care. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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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