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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209323
Report Date: 04/02/2024
Date Signed: 04/04/2024 06:08:03 PM

Substantiated


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
02/29/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240229140618
FACILITY NAME:SEQUOIA GROVE ASSISTED LIVING, INCFACILITY NUMBER:
107209323
ADMINISTRATOR:KEGHOUHY HANDIANFACILITY TYPE:
740
ADDRESS:787 E. MINARETS AVETELEPHONE:
(559) 449-1249
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 4DATE:
04/02/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Keghouhy HandianTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility did not issue a refund to resident's responsible party.
INVESTIGATION FINDINGS:
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On 4/02/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility administrator and stated the purpose of the visit.
During this visit LPA toured the facility inside and out and observed residents in care.
Once the tour was complete, LPA discussed the findings with the AD.

Allegation: Facility did not issue a refund to resident's responsible party. Based off of Administrator interview and file review R1 was not refunded payment of $1,324.82 for the month of January R1 when R1 contract terminated in December. Based on LPAs observations and interviews which were conducted with administrator and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulation is being cited on the attached LIC9099-D
Exit interview conducted, report signed and with appeal rights provided to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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-20240229140618
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: SEQUOIA GROVE ASSISTED LIVING, INC
FACILITY NUMBER: 107209323
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2024
Section Cited
HSC
1569.652
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. This requirement was not met as evidenced by LPA.
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Administrator will review and update Admission agreement and submit a copy to licensing for review. Staff will complete training on regulations and provide copy to LPA by email by POC due date.
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Facility failed to provide refund upon resident's death with in 15 days. Responsible party was charged additional $1,324.82 for whole month of January stay when resident passed away in December. This is poses a potential health and safety or personal rights risk to 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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
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