107208813-8-1-2023-24-AS-BCHN-CUCULT-20230803154117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208813
Report Date: 07/31/2023
Date Signed: 08/01/2023 05:44:56 AM

Unsubstantiated

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
05/08/2023 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230508104516

FACILITY NAME:	MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA		FACILITY NUMBER:	107208813
ADMINISTRATOR:	MAREZ, PHOEUN		FACILITY TYPE:	740
ADDRESS:	292 W TRENTON AVE		TELEPHONE:	(559) 298-7992
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93619
CAPACITY:	6	CENSUS: 6	DATE:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	administrator, Jordan Brice		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility has no food
Staffing is not adequate to meet resident needs

INVESTIGATION FINDINGS:

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On 7/31/23, Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator Nastassha Brice, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegations. Facility was taken care of 5 residents, one of them was under hospice care.

Allegation: Facility has no food

Department reviewed facility records, interviewed residents, staff, and Administrator. During unannounced visits LPAs observed facility staff preparing meals for residents. Facility records provided by AD indicated facility adequately supply facility with groceries. AD provided groceries receipts statements for month of May that indicated that facility shop for groceries weekly. Although the allegation 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.

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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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Control Number 24-AS-20230508104516

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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA	FACILITY NUMBER: 107208813
	VISIT DATE: 07/31/2023

NARRATIVE

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Allegation: Staffing is not adequate to meet resident needs

Department reviewed facility records, interviewed residents, staff, and Administrator. LPAs observed facility had substantial amount of staff. At the time of visit S1 was prepping lunch. S2 was assisting residents in care. Facility schedule records provided by AD upon request for all shifts and NOC included. Although the allegation 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.

Exit interview conducted. No deficiencies were issued during this visit. Report signed and provided for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

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