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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209374
Report Date: 10/29/2024
Date Signed: 10/31/2024 11:25:25 AM

Unfounded


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
09/13/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240913135352
FACILITY NAME:GRAND OAKS ASSISTED LIVINGFACILITY NUMBER:
547209374
ADMINISTRATOR:SHELLHAMER, DAVIDFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:85CENSUS: 48DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Wendi Valdez, Residential Care CoordinatorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
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9
Facility staff did not dispense medications as prescribed
Licensee did not ensure that resident's medication was administered by an appropriately skilled professional
INVESTIGATION FINDINGS:
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2
3
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5
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9
10
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13
On 10/29/24, Licensing Program Analysts (LPAs) L. Salazar and K. Kaur arrived at the facility unannounced to deliver findings on the above allegations. LPAs stated the purpose of their visit and were allowed entry into the facility. LPAs met with Residential Care Coordinator and was available via telephone.

During the investigation, LPA Salazar toured facility, and conducted interviews with staff. Based on the information received,facility staff was giving medication per Dr.'s order and staff were allowed to administer the predosed medication from Hospice.

Based on the information recieved, the allegations Facility staff did not dispense medications as prescribed
and Licensee did not ensure that resident's medication was administered by an appropriately skilled professional are Unfounded. Meaning, that the allegations are false, could not have happened and/or are without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted. No deficiencies cited on today's visit. A copy of report is being emailed to Administrator with a read receipt as proof of delivery.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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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