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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 11:23:04 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
07/25/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240725113052
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):
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9
Staff does not ensure resident medication is administered as needed.
INVESTIGATION FINDINGS:
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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 Adminstrator to discuss the findings. Administrator is out of the facility and was available via telephone.

During the investigation, LPA Salazar reviewed Centrally Strored Medication Destruction Records (CSDMR), Medication Administration Record (MAR), and observed 9 out of 23 days in April 2024, Resident R1 did not recieve their medication. LPA interviewed facility Staff S1, who signed off on the MAR. S1 stated they could not read the blood sugar levels and documented as "HI" and did not administer medication on 9 our of the 23 days recorded.

Based on LPA’s observation of records and interview with Staff S1, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted with Administrator via telephone and a Plan of correction was developed. A copy of this report and appeal rights were discussed and will be provided to Administrator A plan of correction was developed by licensee and reviewed with LPA.


Substantiated
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)
Page: 1 of 3
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
07/25/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240725113052

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
2
3
4
5
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7
8
9
Staff does not leave resident’s walker within reach for resident.
Staff does not ensure pull cord is accessible to resident.
INVESTIGATION FINDINGS:
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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 to discuss the findings. Administrator is out of the facility and was available via telephone.

During the investigation, LPA Salazar toured facility and conducted interviews with staff. Based on the information received ,and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations, Staff does not leave resident’s walker within reach for resident and Staff does not ensure pull cord is accessible to residents occured. Therefore the findings are found to be Unsubstantiated.

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.
Unsubstantiated
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)
Page: 2 of 3
Control Number 24-AS-20240725113052
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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4)The licensee shall assist residents with self-administered medications as needed.

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Administrator was provided with TSP medicaiton guide. Administrator will provide a statement stating they have read and understood the CCR Title 22 medication requirements by POC date.
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This requirement was not met as evidenced by LPA's observation of Resident R1's records (CSMDR, MARS) and interview with Staff S1. R1 did not receive medication on 9 out of 23 days on the April 2024 MAR.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3