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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208801
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:09:36 PM

Unfounded


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
12/02/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211202090745
FACILITY NAME:FRESNO GUEST HOME XIFACILITY NUMBER:
107208801
ADMINISTRATOR:ANGELICA KUTNERIAN GLESSFACILITY TYPE:
740
ADDRESS:2562 E MAGILL AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 6DATE:
07/19/2022
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Angela Kutnerian, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident fell while in care
Staff are not providing adequate laundry services for resident
Kitchen sink is in disrepair
Facility doesn't have toiletry products for resident's
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Sergiy Pidgirny and Licensing Program Analyst (LPA) Lady Cabrera the subsequent complaint visit. LPA met with Administrator Angela Kutnerian and delivered investigation findings regarding the above allegations.

During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegations: Resident fell while in care, Staff are not providing adequate laundry services for resident, Kitchen sink is in disrepair, and Facility doesn't have toiletry products for resident's are UNFOUNDED. We have found that the complaint was Unfounded, therefore we have dismissed the complaint.

The Department conducted interviews with staff and reviewed records. Based on interviews and records, on 08/15/2022 Resident (R1) fell at the facility and staff immediately evaluated and assisted R1. Facility Administrator reported R1 had no injuries from the fall and R1’s responsible party was notified. According to R1’s Primary Physician, R1 had history of falls.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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
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
12/02/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20211202090745

FACILITY NAME:FRESNO GUEST HOME XIFACILITY NUMBER:
107208801
ADMINISTRATOR:ANGELICA KUTNERIAN GLESSFACILITY TYPE:
740
ADDRESS:2562 E MAGILL AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 6DATE:
07/19/2022
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Angela Kutnerian, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained fractures while in care
Resident sustained unexplained bruising while in care
Staff are not meeting resident's hygiene needs.
Dishes have mold
Staff did not safeguard resident's personal belongings
Staff did not notify resident's authorized representatives of incidents
Lack of communication regarding resident's care
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Sergiy Pidgirny and Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Resident sustained unexplained fractures while in care, Resident sustained unexplained bruising while in care, Staff are not meeting resident's hygiene needs and Dishes have mold.
The Department conducted interviews with staff and reviewed records. Resident (R1) complained of low back pain and primary physician requested x-rays. Per medical records reviewed, R1 unexplained moderate compression fracture was undetermined and indicated degenerative changes.

Per interviews conducted, R1 is independent, mobile and ambulated at the facility. R1 needed reminders to use the walker. R1 is diagnosed with Alzheimer’s and is unable to explain how the bruises occurred. According to R1’s primary physician, R1 had history of falls. Per interviews, staff have not been observed to be rough or inappropriate with R1 and R1 would frequently bump into walls while ambulating. Based on interviews and records reviewed, it is unclear how R1 sustained the bruises while in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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
Control Number 24-AS-20211202090745
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: FRESNO GUEST HOME XI
FACILITY NUMBER: 107208801
VISIT DATE: 07/19/2022
NARRATIVE
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Based on interviews and records, R1 received a full shower twice a week and as needed showers if resident experienced an accident. A photo was submitted to Community Care Licensing (CCL) indicating R1 had dried fecal material on foot. LPA was unable to determine from the photo if R1 had dried fecal material. Per Administrator, she was unaware of this incident. Per interviews, staff would shower R1 twice a week and more if needed and assist residents with hygiene needs.

A photo was submitted to CCL regarding R1’s sippy cup with built in straw had mold. LPA was unable to determine from the photo if R1’s sippy cup had mold. Per Administrator, this was not reported to her. Per interviews, the sippy cups are soaked in one-part bleach and three cups of water over night and the morning staff will wash by hand.

Based on interviews conducted, Resident’s (R1) family notified Administrator regarding missing personal belongings. R1’s belongings were not returned to R1’s responsible party upon discharge and a signed receipt was not provided. According to the Administrator, the day of R1’s discharge all personal belongings were found and provided to R1’s responsible party. Per records reviewed, R1’s Personal Property and Valuables form (LIC621) was not updated and did not indicate missing belongings.

It was reported that staff did not notify resident’s authorized representatives of incidents and lack of communication regarding resident’s care; such as when R1 was scheduled for the flu shot, chest x-ray, urine analysis and blood work. It was reported R1’s responsible party was notified after R1 was seen by her primary physician. Per primary physician, in care homes where administrators are actively involved in all facets of care for their residents, they deem it more efficient to notify them of all the changes, so they can relate the messages and updates to the resident or their responsible party. Based on interviews and records reviewed, R1’s responsible party signed the flu and pneumonia vaccine consent, the new patient enrollment form and acknowledgement of their acceptance policies for R1 to be seen by the primary physician at the facility.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20211202090745
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: FRESNO GUEST HOME XI
FACILITY NUMBER: 107208801
VISIT DATE: 07/19/2022
NARRATIVE
1
2
3
4
5
6
7
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Based on the interviews conducted and records reviewed the above allegations are 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 allegations are unsubstantiated.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4