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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209349
Report Date: 04/09/2024
Date Signed: 04/16/2024 12:26:40 AM

Substantiated


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
04/09/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240409081257
FACILITY NAME:AILE ASSISTED LIVINGFACILITY NUMBER:
547209349
ADMINISTRATOR:CERVANES, ARMANDOFACILITY TYPE:
740
ADDRESS:1542 E. GLENWOOD AVENUETELEPHONE:
(408) 420-7538
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 0DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator/Licensee
Armando Cervantes, via telephone 		TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not fingerprint cleared to work in facility
Staff left resident at facility unsupervised
Lack of supervision resulted in resident’s needs not being met
Residents were issued improper eviction notices
INVESTIGATION FINDINGS:
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On 04/09/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounvced to conduct the required 10 day site visit. LPA contacted Licensee via telephone and stated the purpose of the visit. Prior to the visit, LPA reviewed records.

A review of facility's roster for criminal records clearance shows Staff S1 does not have a criminal record clearance and needs an exemption approval prior to working. A review of law enforcement records include interviews with staff stating Staff S2 left the facility, while being the only staff on duty, resulting in Resident R1 being left with the absence of care and supervision. R1's care needs require total assistance with activities of daily living. R1 was left unsupervised and left soiled on mutiple occassions.

A review of facility file and interviews with staff show Licensee/Administrator did not provide a proper written notice of facility closure to residents as required, resulting in the family struggling to find emegency placement suitable for R1's care needs.

Based on the information received, the preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached 9099-D. A civil penalty in the amount of $500 is being assessed for the lack of care and supervision. An additioanal civil penalty in the amount of $500 is being assessed for no Criminal Background clearance.

A copy of this report and appeal rights were sent via email due to Licensee being out of the area. Licensee will send signed copy of report to LPA via email upon receipt. Plans of corrections are cleared due to Licensee surrendering the license and there are no residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
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 3
Control Number 24-AS-20240409081257
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: AILE ASSISTED LIVING
FACILITY NUMBER: 547209349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
87411(g)(1)
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87411 Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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Licensee provided LPA with Staff S1's personnel file.
- POC Cleared -

**Civil Penalty Assessed**
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This requirement was not met as evidenced by records review. Staff S1 was not fingerprint cleared to work in the facility. Documentation shows an exemption for S1 is required before working. S1 worked over 30 days in the facility. This poses an immediate risk to the health and safety of the residents in care. An immediate civil penalty in the amount of $500 is hereby assessed.
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Type A
04/09/2024
Section Cited
HSC
1569.628(a)(2)(A)
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§1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties
(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following: (2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following: (A) The reason for the eviction, with specific facts to permit a determination of the date, place, witnesses, and circumstances concerning the reasons.
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Licensee has surrendered licensee. Health and Safety Inspection completed, no residents in facility. Licensee provided locations of relocations of residents.
- POC cleared-
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This requirement was not met as evidenced by LPAs observation of closure letter and staff interviews. Residents were given a verbal notice less than two weeks prior to closing the facility. This poses and immediate risk to the health safety and personal rights of residents 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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240409081257
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: AILE ASSISTED LIVING
FACILITY NUMBER: 547209349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
HSC
1569.49(c)(3)
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1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation... for any of the following serious violations: (3) Absence of supervision as required by statute or regulation. This requirement was not met as evidenced by:
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Licensee has surrendered licensee. Health and Safety Inspection completed, no residents in facility.
-POC cleared-
*Civil Penalty Assessed**
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LPA's observation of documentation received from licensee and Law enforcement. S2 left the facility,resulting in the absence of supervision for Resident R1, whose care needs require total assistance on others for activities of daily living.
This posed an immediate risk to the health safety and personal rights of residents in care. A civil penalty is hereby assesed in the amount of $500, for the lack of care and supervision.


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Type A
04/09/2024
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Licensee has surrendered licensee, LPA obtained. Health and Safety Inspection completed, no residents in facility.
- POC cleared -
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This requirement was not met as evidenced by LPA's records review of law enforcement report that include statements from mutiple staff, that S1 has left R1 alone, unattended resulting in R1 remaining in soiled linens for long periods of time.
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3