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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206858
Report Date: 02/10/2025
Date Signed: 02/10/2025 01:47:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/31/2024 and conducted by Evaluator Jacques Leffall
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241231112358
FACILITY NAME:A PLACE CALLED HOME RESIDENTIAL CARE 3FACILITY NUMBER:
107206858
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2822 CALIMYRNA AVETELEPHONE:
(559) 326-0870
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver: Liz JugalTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not ensure supervision was provided resulting in resident sustaining injuries while in care

Staff did not ensure reporting requirements were followed
INVESTIGATION FINDINGS:
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On 2/10/25 at 1:00pm Licensing Program Analyst (LPA) J. Leffall conducted a subsequent complaint visit to deliver findings on above allegations. LPA met with Staff (S1) Liz Jugal and stated purpose of visit.

The Department reviewed records and conducted interviews.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued.

Exit interview conducted. A copy of this report was distributed to Staff which confirms signature of report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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
FRESNO RO, 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
12/31/2024 and conducted by Evaluator Jacques Leffall
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241231112358

FACILITY NAME:A PLACE CALLED HOME RESIDENTIAL CARE 3FACILITY NUMBER:
107206858
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2822 CALIMYRNA AVETELEPHONE:
(559) 326-0870
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver: Liz JugalTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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On 2/10/25 at 1:30 pm Licensing Program Analyst (LPA) J. Leffall conducted a subsequent complaint visit to deliver findings on above allegations. LPA met with Staff (S1) Liz Jugal and stated purpose of visit.

The Department reviewed records and conducted interviews. R1 was complaining of pain to her legs when facility staff found her off of wheelchair on 11/27/24. Staff contacted Administrator David, and told him she did not think EMS services were necessary.

Facility did not get R1 medically assessed. R1’s bruising and swollenness to her ankle were not seen by staff until the morning of 11/29/24 when she continued to complain of pain. Staff contacted R1’s daughter who contacted R1’s Physician.

Based on the interviews conducted, the preponderance of evidence that Staff did not seek medical attention for resident in a timely manner is substantiated. Citation is issued on the attached 9099D.

The issuance of civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit interview conducted. Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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-20241231112358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL CARE 3
FACILITY NUMBER: 107206858
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2025
Section Cited
CCR
8741(d)(5)
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 (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.
This requirement was not met by based on interviews conducted and records review, R1 complained of pain after being found on the floor off of her wheelchair and staff did not seek medical attention or contact R1’s Physician which poses an immediate health and safety risk to residents in care.
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Administrator states will exercise Appeal rights at a later date.

Administrator intends to file a complaint on the Investigator who conducted the Investigation.
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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: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3