107208764-8-13-2021-24-AS-SPIY-C63R3E-20210820123948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208764
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:42:45 PM

Unsubstantiated

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
05/10/2021 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210510115136

FACILITY NAME:	WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLC		FACILITY NUMBER:	107208764
ADMINISTRATOR:	RUNDERSON, MARTHA M		FACILITY TYPE:	740
ADDRESS:	2909 EAST GRIFFITH WAY		TELEPHONE:	(559) 226-1082
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	3	CENSUS: 1	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff, Twioneshia Miles		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Staff caused an injury to a resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced visit to deliver complaint findings. LPA Williams met with Staff Twionesha Miles and discussed the purpose of the visit.

The Department has investigated the above allegation, interviewed witnesses and outside agencies, conducted record reviews, and made observations at the facility.

Although the allegation, staff caused injury to a resident while in care, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Administrator Martha Runderson provided verbal approval via phone for staff to sign the report. An exit interview was conducted and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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