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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209324
Report Date: 09/05/2024
Date Signed: 09/29/2024 04:39:56 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
05/14/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240514083051
FACILITY NAME:GROVE, THEFACILITY NUMBER:
107209324
ADMINISTRATOR:BREWER, NORSHELLFACILITY TYPE:
740
ADDRESS:7444 NORTH CEDAR AVETELEPHONE:
(801) 815-0808
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:130CENSUS: 70DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Administrator Norshell BrewerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication.
Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Norshell Brewer, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegations.

Allegation: Staff mismanaged resident’s medication.

On 05/16/2024, during complaint investigation department reviewed facility records, interviewed staff and Administrator, and observed medications storage and dispensing for R1 and R2 accordingly. 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-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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 2
Control Number 24-AS-20240514083051
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: GROVE, THE
FACILITY NUMBER: 107209324
VISIT DATE: 09/05/2024
NARRATIVE
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32
This is an amended report.
Allegation: Staff did not administer resident's medication as prescribed.

During complaint investigation department reviewed facility records, interviewed staff and Administrator, and observed the staff and residents during medication administration. Records review and interviews revealed that in July, 2024 medications were administered to residents as prescribed. 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.

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

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2