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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107207121
Report Date: 10/15/2021
Date Signed: 10/20/2021 08:16:08 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
07/16/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210716112844
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- Assistant-AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident care needs are not being met
Facility did not safeguard resident's belongings
Facility did not issue refund
INVESTIGATION FINDINGS:
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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 inspected the facility, conducted interviews and reviewed records. According to statements from staff and the Responsible Party for Resident 1(R1), facility staff served R1 dairy products on more than one occasion, contrary to the agreed upon care plan for R1. Facility staff have not been able to account for at least one item of clothing belonging to R1 upon her vacating the facility. The licensee did not specify in the admission agreement for R1 the montlhly rate, and the admission agreement was not signed by all parties. The responsible party of R1 has requested a refund of $1498.90 after moving R1 from the facility. 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 4
Control Number 24-AS-20210716112844
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
87464(f)(3)
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87464(f)(3) Basic Services: Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor... This requirement was not met as evidenced by:
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Administrator shall provide LPA with a plan of correction by POC due date.
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Based on interviews and records, facility staff served R1, who is lactose-intolerant dairy products. This presents a potential health and safety risk.
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Type B
10/29/2021
Section Cited
CCR
87507(c)
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87507 Admission Agreements: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met as evidenced by:
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The licensee will provide proof of payment for a refund of $1498.90 to R1's responsible party by POC due date.
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Based on records review, the licensee failed to ensure that the admission agreement was signed and that the agreed upon monthly rate was clearly communicated in writing.
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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: 4 of 4
Control Number 24-AS-20210716112844
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
87217(i)
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87217(i) Safeguards for Resident Cash, Personal Property, and Valuables: Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident, or his responsible person. This requirement was not met as evidenced by:
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Based on interviews and records reviewed, the licensee failed to return all of R1's property to her responsible party upon discharge from the faility.
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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 4
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
07/16/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210716112844

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:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication is not being administered
Food quality is poor
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
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 inspected the facility, conducted interviews, and reviewed records. Based upon records and interviews, facility staff administered medciation properly and abided by doctors' orders. During inspection, food stuffs were adequate in wlauity and quantity. During interviews, residents stated that the food was of fair quality and that staff prepared meals which were to their liking. The above allegations are unsubstantiated. Exit interview conducted. A copy of the report was provided to the licnesee via email.
Unsubstantiated
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 4