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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208986
Report Date: 07/25/2023
Date Signed: 07/31/2023 11:12:35 AM

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
02/06/2023 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230206161901
FACILITY NAME:FRESNO GUEST HOME XIIFACILITY NUMBER:
107208986
ADMINISTRATOR:KUTNERIAN, GEORGEFACILITY TYPE:
740
ADDRESS:2398 E. LOS ALTOS AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 6DATE:
07/25/2023
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Terri PhanhnouvongTIME COMPLETED:
05:26 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not notify representative of residents fall
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. I met with staff Terri Phanhnouvong (designated substitute) and spoke to Administrator Angela Kutnerian on the phone and informed them the purpose of the visit.
During this visit LPA delivered investigation findings regarding the above allegation.The Department has investigated the complaint alleging: Facility did not notify representative of residents fall. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegations 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 allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
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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