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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107207121
Report Date: 10/15/2021
Date Signed: 10/19/2021 08:32:42 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
06/04/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210604160510
FACILITY NAME:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR:RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Leticia Rodriguez-AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Facility refused to take back COVID-19 positive resident from hospital
INVESTIGATION FINDINGS:
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13
On this date, Licensing Program Analyst (LPA) David Ayers arrived unannounced to deliver complaint findings. LPA identified himself and discussed the purpose of the visit with Administrator Leticia Rodriguez.

During the course of the investigation, the department conducted interviews and reviewed records. On 6/4/2021, the facility refused to accept a COVID-19 positive resident back into the facility from Kaiser Hospital. The Licensee stated that she would not accept the resident back into the facility due to the risk to her other residents. See attached 9099D for deficiency cited in accordance with California Code of Regulations Title 22. Exit interview conducted. A copy of this report and appeal rights will be provided via email. A read receipt confirms the Licensee receives these documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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
Control Number 24-AS-20210604160510
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: NINA'S HOME
FACILITY NUMBER: 107207121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to provide LPA with POC by due date.
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Based on interviews and records reviewed, the Licensee failed to provide Resident 1(R1) with accomodations per R1's admission agreement. This presents a potential health and safety risk to residents in care.
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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: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
06/04/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210604160510

FACILITY NAME:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR:RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Leticia Rodriguez-AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
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13
On this date, Licensing Program Analyst (LPA) David Ayers arrived unannounced to deliver complaint findings. LPA identified himself and discussed the purpose of the visit with Administrator Leticia Rodriguez.

During the course of the investigation, the department conducted interviews and reviewed records. Based on statements from the Licensee and the Responsible Party for Resident 1(R1), both parties came to an agreement for R1 to reside at her family's home during her quarantine period. No eviction notice was issued in writing or verbally. Exit interview conducted. A copy of this report will be provided via email. A read receipt confirms the Licensee receives these documents.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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