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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209480
Report Date: 03/18/2026
Date Signed: 03/18/2026 02:29:01 PM

Substantiated


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
02/19/2026 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20260219132210
FACILITY NAME:STONEHAVEN SENIOR LIVINGFACILITY NUMBER:
107209480
ADMINISTRATOR:SALOW, DONALDFACILITY TYPE:
740
ADDRESS:1717 SOUTH WINERY AVENUETELEPHONE:
(659) 251-8417
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:116CENSUS: 100DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Mike Salway
Radhika Jawa		TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff forged a resident's signature
INVESTIGATION FINDINGS:
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On 3/18/2026, Licensing Program Analyst (LPA) M. Medina conducted a subsequent complaint visit to gather additional information and deliveri findings for complaint.

During the investigation, LPA conducted interviews, gathered information and toured facility. Based on information gathered during interviews and documentation reviewed, Resident (1) provided paperwork to LPA with their signature on a form and stated that they had not signed it. During an internal investigation conducted by facility after initial complaint visit on 2/23/2026, it was determined that a former staff who was working on special project, which included all resident's medical assessments faxed over a signed document to R1's physician, which R1 did not sign.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.

Exit interview conducted and a copy of report and appeal rights provided for facility records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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 3
Control Number 24-AS-20260219132210
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 107209480
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2026
Section Cited
CCR
87207
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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

**This was not met as evidenced by: Resident (1) provided paperwork to LPA h
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Administrator to conduct training with staff regarding regulation and submit agenda and sign in sheet to Fresno Regional office by POC due date.
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with their signature on a form and stated that they had not signed it. During an internal investigation conducted by facility after initial complaint visit on 2/23/2026, it was determined that a former staff who was working on special project, which included all resident's medical assessments faxed over a signed document to R1's physician, which R1 did not sign.
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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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/19/2026 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20260219132210

FACILITY NAME:STONEHAVEN SENIOR LIVINGFACILITY NUMBER:
107209480
ADMINISTRATOR:SALOW, DONALDFACILITY TYPE:
740
ADDRESS:1717 SOUTH WINERY AVENUETELEPHONE:
(659) 251-8417
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:116CENSUS: 100DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Mike Salway
Radhika Jawa		TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Staff are not following resident's dietary plan
INVESTIGATION FINDINGS:
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On 3/18/2026, Licensing Program Analyst (LPA) M. Medina conducted a subsequent complaint visit to gather additional information and deliver findings for complaint.

During the investigation, LPA conducted interviews, gathered information and toured facility. Based on information gathered during interviews and documentation reviewed, There is no physician order for a special diet on file for Resident (1) with facility R1 does have a dietary preferences sheet which is completed after admission by Dietary manager with resident present, and updated as needed.

This Department has found that the above allegations is UNFOUNDED, meaning they were false, could not have happened, and/or were without reasonable basis. We have therefore dismissed the complaint.

No deficiencies issued during this complaint visit . Exit interview conducted. A copy of this report was provided to Administrator for facility records
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3