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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209164
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:24:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/19/2024 and conducted by Evaluator Jacques Leffall
COMPLAINT CONTROL NUMBER: 24-AS-20241219120418
FACILITY NAME:DIGNITY MANOR SENIOR HOMEFACILITY NUMBER:
107209164
ADMINISTRATOR:GAYNOR, DONTEFACILITY TYPE:
740
ADDRESS:1828 SANTA ANA AVE.TELEPHONE:
(559) 917-0440
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator: Camala Kopazz TIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident developing maggots in the mouth
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/6/225 at 1:15pm Licensing Program Analyst (LPA) J. Leffall conducted a subsequent complaint visit to deliver findings on above allegations. LPA met with Licensee (L1) Camala Kopazz and stated purpose of visit.

The department conducted interviews and reviewed records. Based on the information obtained, the above allegation is unsubstantiated.

Exit interview conducted.

A copy of this report was provided to Licensee, whose signature on this form confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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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