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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208813
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:44:20 PM

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
03/04/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240304102705
FACILITY NAME:MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEAFACILITY NUMBER:
107208813
ADMINISTRATOR:MAREZ, PHOEUNFACILITY TYPE:
740
ADDRESS:292 W TRENTON AVETELEPHONE:
(559) 298-7992
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 5DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Grace Petil, staffTIME COMPLETED:
11:34 AM
ALLEGATION(S):
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Staff did not follow resident's diet
Staff did not assist resident in a timely manner
Staff took resident's personal items
Uncleared staff working at the facility
INVESTIGATION FINDINGS:
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On 07/30/2024, Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator Grace Petil, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegation.

Allegation: Staff did not assist resident in a timely manner, Staff took resident's personal items, Uncleared staff working at the facility. Staff did not follow resident's diet.

During complaint investigation department reviewed facility records, staff training, interviewed staff and Administrator, and observed the staff and residents during facility visits. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Report continues on attached LIC9099-A
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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 4
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
03/04/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240304102705

FACILITY NAME:MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEAFACILITY NUMBER:
107208813
ADMINISTRATOR:MAREZ, PHOEUNFACILITY TYPE:
740
ADDRESS:292 W TRENTON AVETELEPHONE:
(559) 298-7992
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 5DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Grace Petil, staffTIME COMPLETED:
11:34 AM
ALLEGATION(S):
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9
Resident sustained unexplained injury while in care
Staff did not assist resident with their medication
INVESTIGATION FINDINGS:
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This is an amended report.
On 09/24/2024, Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator Grace Petil, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegation.

Allegation: Resident sustained unexplained injury while in care. During staff interview and records review revealed that R1 injury was not reported to CCL or documented in records. During staff interview it was revealed that it was unknown how R1 received injury while in care. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099D.

Report continues on attached LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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-20240304102705
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: 07/30/2024
NARRATIVE
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Allegation: Staff did not assist resident with their medication. Based on interviews conducted and records review it was revealed that on multiple occasions, 01/06, 01/07, and 01/08 R1 was not provided medications by staff as ordered. Based on staff interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations being cited on the attached LIC 9099-D.

Exit interview conducted, report signed and copy of this report with appeal rights provided to Administrator for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20240304102705
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations.
This requirement was not observed as evidenced by:
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Administrator and staff will ensure facility staff are following with family and close monitoring residents all day around, keeping family and updating social worker on residents health. Also provide training to LPA by POC due date
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Based on witnesses interviews and records review R1 was not provided care to injured right foot. The facility staff failed to offer resident medical evaluation to the injured right foot which poses potential threat to health and safety of the residentts in care.
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Type B
08/02/2024
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not observed as evidenced by:
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Administrator will ensure facility staff are monitoring medications refill and following medications orders. Also provide staff training to LPA by POC due date
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Based on witnesses interview and records review R1 did not receive medications as prescribed. Which poses potential threat to health and safety of the residents in care.
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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: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4