107208986-7-31-2023-24-AS-SPIY-CUDNG4-20230804102633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

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

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
02/06/2023 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230206161901

FACILITY NAME:	FRESNO GUEST HOME XII		FACILITY NUMBER:	107208986
ADMINISTRATOR:	KUTNERIAN, GEORGE		FACILITY TYPE:	740
ADDRESS:	2398 E. LOS ALTOS AVENUE		TELEPHONE:	(559) 434-1839
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Terri Phanhnouvong		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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2
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9

Facility does not supervise residents

INVESTIGATION FINDINGS:

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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 the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Facility does not supervise residents is UNFOUNDED. Resident R1 had an unwitnessed fall and was provided immediate assessment and/or assistance by the facility staff. Medical care was provided timely for resident. This agency has investigated the complaint alleging (Facility does not supervise residents). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
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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