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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206937
Report Date: 02/13/2023
Date Signed: 02/16/2023 02:16:26 PM

Unsubstantiated


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
11/22/2022 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221122141804
FACILITY NAME:BACKER SENIOR CAREHOMEFACILITY NUMBER:
107206937
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:9127 N BACKER AVETELEPHONE:
(559) 721-5483
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
02/13/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Arlene Bautista, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff are verbally/aggressively abusive to resident.
Facility staff are preventing resident from having contact with family.
Facility staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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On 02//13/2023, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to deliver findings. LPA met with Administrator Arlene Bautista and Licensee Lisa Pua. LPA explained the reason for the visit.
The Department has investigated the complaint alleging:

Facility staff verbally/aggressively abusive to resident. LPA interviewed residents. Based on the interviews conducted and records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Facility staff preventing resident from having contact with family. LPA interviewed staff, family member and residents. Family requested resident’s phone to be taken away. Based on the interviews conducted and
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
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 2
Control Number 24-AS-20221122141804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BACKER SENIOR CAREHOME
FACILITY NUMBER: 107206937
VISIT DATE: 02/13/2023
NARRATIVE
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records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Facility staff did not follow reporting requirements. RP did not provided evidence to allegation. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted. No deficiency were observed on this visit. Copy of this report was provided for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2