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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107207121
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:55:08 PM

Substantiated


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
04/17/2024 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20240417091828
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: 4DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Administrator, Leticia RodriguezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff does not administer resident's medication as prescribed
Staff did not ensure that a resident's medication was stored locked
Staff do not safeguard residents' personal belongings
Staff do not treat resident with dignity and respect
Staff do not ensure that residents are properly supervised
Staff handled a resident in a rough manner
Staff do not meet a resident's dietary needs
INVESTIGATION FINDINGS:
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On 10/03/2024 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced visit to deliver complaint findings. LPA met with Administrator, Leticia Rodriguez, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas and in rooms.

During the investigation interviews were completed and documentation was reviewed. The following was found:

Allegation: Staff does not administer resident's medication as prescribed
During record review of the MARs, LPA observed that R1 was not being provided their prescription of Ativan as prescribed. Record review (4/1/2024 and 4/12/2024) showed that R1 was receiving their medication (3 mg every 2 hrs.) but should have been receiving (1mg every 4 hrs.). On 4/14/2024, R1 had a missed medication at 7am and did not receive it in the required timeframe (rec’vd @1pm). R1 has a prescription for use of Thicken in liquids but staff is not providing it. This allegation is SUBSTANTIATED. CONT...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 5
Control Number 24-AS-20240417091828
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: NINA'S HOME
FACILITY NUMBER: 107207121
VISIT DATE: 10/03/2024
NARRATIVE
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CONT...Allegation: Staff did not ensure that a resident's medication was stored locked
During investigation LPA completed interviews with RP and received pictures provided by RP. RP disclosed that the facility has medication throughout the facility that are unlocked and accessible to residents in care. Pictures provided showed medications in an unlocked dresser drawer. During LPAs visit to the facility on 4/19/24 medications were unlocked inside the refrigerator. This allegation is SUBSTANTIATED.
Allegation: Staff do not safeguard residents' personal belongings
During investigation RP alleged facility did not safeguard R1 and R2’s personal belongings. During review of the admission agreements, it was observed items were not itemized by the licensee but by the family only. Items still not located at move out: laptop, hearing aids, wheelchairs, clothes, medications, supplies for R1 and R2. Documentation does not support that these items were not properly safeguarded and returned to residents upon move out. This allegation is SUBSTANTIATED.
Allegation: Staff do not treat resident with dignity and respect
During interviews with staff and RP it was disclosed that staff are taking photographs and videos of R1 and sending them to the Licensee. Staff do not have the family’s consent to do this. These pictures/videos were of R1 in compromising positions/incidents and inappropriate to take. During a visit on 4/19/24 LPA observed staff walking into residents’ rooms without permission to enter, moving a resident without explanation and staff raising their voice at R2. This allegation is SUBSTANTIATED.
Allegation: Staff do not ensure that residents are properly supervised
During interviews with RP and staff it was disclosed that staff are sleeping during the night shift. Interviews disclosed R2 had a drop in their glucose levels and called for assistance, but staff did not come to assist them. During review of documentation, it was observed that R1 wanders throughout the night and R2 needs assistance with their medical condition. This allegation is SUBSTANTIATED.
Allegation: Staff handled a resident in a rough manner
During interview with RP it was disclosed caregivers laugh and mock R1 when needing assistance. Interview disclosed RP observed S1 pulling R1 in a rough manner while transferring without assistance. During visit on 4/19/24 LPA observed staff pick up R1 from a sitting position and lay them down on the couch without notifying R1 they were going to move them. R1 showed signs of pain by saying “ouch” and rubbing their legs. LPA asked if their leg hurt and R1 replied “yes”. This allegation is SUBSTANTIATED.
Allegation: Staff do not meet a resident's dietary needs
During investigation LPA completed interviews with RP, staff and residents, completed visits of the facility and reviewed documentation. During facility visit on 4/19/24 LPA observed expired food in the pantry, improperly stored food in refrigerator/freezer and observed staff cooking. Interviews with residents indicated they do not have a variety of food served that is meeting their dietary needs. This allegation is SUBSTANTIATED.
The allegations listed above have been found to be SUBSTANTIATED per Title 22. Deficiencies cited on attached 9099D.
Exit interview completed with Administrator, Leticia. A copy of this report, deficiencies, and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20240417091828
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: NINA'S HOME
FACILITY NUMBER: 107207121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.
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Facility will provided POC in writting to CCL by POC date.
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This requirement was not met as evidence by LPA observation of MARS reviewed from 4/1/24-4/12/24 showing R1 did not receive their medications as prescribed. It was also observed that R1 was not being provided liquids with thicken during a visit conducted on 4/19/24.
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Type B
10/14/2024
Section Cited
CCR
87309(a)(1)
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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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This requirement was not met as evidence by: LPA observation of pictures provided by RP of medications unlock in a dresser drawer, medications unlocked in the facility refrigerator and drawers during a visit on 4/19/24.
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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: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240417091828
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: NINA'S HOME
FACILITY NUMBER: 107207121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2024
Section Cited
HSC
1569.153(d)
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1569.153 Theft and loss program; standards, property inventories and surrender of personal effects; secured areas
A theft and loss program shall be implemented by the residential care facilities...include all of the following:... A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility...
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Items that are currently unaccounted for by facility will be looked for an returned to families. Administrator to provide receipt of items to CCL as verification of items returned. Administrator stated that all staff training will be completed. Administrator will provide a in-service sign in sheet and training material to CCL by POC date.
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This requirement was not met as evidence by: LPA’s review of the admission agreement and interview with RP disclosing R1 and R2 did not discharge with all of their belongings/medication/supplies.
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Type B
10/14/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a)...(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance...
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Administrator stated that all staff training will be completed. Administrator will provide a in-service sign in sheet and training material to CCL by POC date.
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This requirement was not met as evidence by: LPA interviews disclosing staff are taking photographs/videos of R1 without consent. LPA observation of staff walking into residents’ rooms without permission to enter. Moving R1 in a rough manner without explanation. Raising their voices at R2 during visit on 4/19/24.

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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: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 24-AS-20240417091828
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: NINA'S HOME
FACILITY NUMBER: 107207121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87705(c)(4)(A)
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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia... (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs...(A)... shall have at least one night staff person awake and on duty...
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Administrator stated they will replace batteries in all call buttons to ensure they are functioning properly. Administrator stated that all staff training will be completed. Administrator will provide a in-service sign in sheet and training material to CCL by POC date.
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This requirement was not met as evidence by: LPA interviews staff they are sleeping during the night shift. Documentation reviewed shows R1 wanders throughout the night and R2 needs assistance with their medical condition.
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Type B
10/14/2024
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements
(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Administrator stated that all staff training will be completed. Administrator will provide a in-service sign in sheet and training material to CCL by POC date.
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This requirement was not met as evidence by: LPA observations on 4/19/24 of expired food in the pantry, improperly stored food in refrigerator/freezer and observed staff cooking. Interviews conducted with residents indicated residents do not have a variety of food served that is meeting their dietary needs.
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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: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5