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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206562
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:58:46 PM

Unfounded


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
12/05/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20231205081924
FACILITY NAME:GREEN VILLAFACILITY NUMBER:
107206562
ADMINISTRATOR:SANTOS, CARLOSFACILITY TYPE:
740
ADDRESS:1463 W. SIERRATELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
03/06/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Care Staff Rene Valencia TIME COMPLETED:
02:54 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries and bruises due to staff neglect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted interviews and reviewed records. Based on records reviewed, R1 unwitnessed fall and was transported to the hospital. Interviews conducted indicated R1’s skin condition/skin tears were consistent with her behaviors. The allegation is Unfounded and we have therefore dismissed the complaint. Exit interview was conducted.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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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