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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206591
Report Date: 09/06/2022
Date Signed: 09/06/2022 04:52:45 PM

Substantiated


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
06/15/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220615143225
FACILITY NAME:ARCADIA FAMILY CAREFACILITY NUMBER:
157206591
ADMINISTRATOR:YATCO, JERRYFACILITY TYPE:
740
ADDRESS:8306 SHIPROCK DRIVETELEPHONE:
(661) 587-0370
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 6DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Jasmin YatcoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident was not provided adequate care while in care.
Facility not communicating with authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver complaint investigation findings to the facility. LPA met with and explained the purpose of the visit with Jasmin Yatco.

The Department investigated the allegation: Resident was not provided adequate care while in care. During the course of the investigation, interviews were conducted and Resident (R1’s) facility file was reviewed. A video and pictures were provided and include date confirmation of the incident. Text messages were provided that confirm that the facility was not able to meet R1’s care needs.

The Department investigated the allegation: Facility not communicating with authorized representative. During the course of the investigation interviews were conducted and pictures were provided and reviewed. The timestamp on the pictures of the text conversation confirm that R1’s Representative was not notified of the incident and R1’s condition and needs until the following morning.

See LIC 9099C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
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 4
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
06/15/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220615143225

FACILITY NAME:ARCADIA FAMILY CAREFACILITY NUMBER:
157206591
ADMINISTRATOR:YATCO, JERRYFACILITY TYPE:
740
ADDRESS:8306 SHIPROCK DRIVETELEPHONE:
(661) 587-0370
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Jasmin YatcoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Staff inappropriately speak to resident(s).
INVESTIGATION FINDINGS:
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5
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8
9
10
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12
13
Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver complaint investigation findings to the facility. LPA met with and explained the purpose of the visit with Jasmin Yatco.

The Department investigated the allegation: Staff inappropriately speak to resident(s). During the course of the investigation interviews were conducted. Based on interviews, it was unable to be confirmed if staff spoke inappropriately to residents.

The allegation above is UNSUBSTANTIATED. Although the allegations may have happened or are valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of this report was left with AD Jasmin Yatco, whose signature on this form confirm receipt of these documents

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20220615143225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ARCADIA FAMILY CARE
FACILITY NUMBER: 157206591
VISIT DATE: 09/06/2022
NARRATIVE
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Based on interview and record review and observation of video and pictures, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.



















An exit interview was conducted and Plans of Corrections were reviewed and developed. A copy of this report and Appeal Rights were discussed and left with Administrator Jasmin Yatco, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20220615143225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ARCADIA FAMILY CARE
FACILITY NUMBER: 157206591
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2022
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement was not met as evidenced by:
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Facility has agreed to provide staff inservice to review all aspects of care and supervision. A review of when to call for Emergency Medical Services will also be conducted. Administrator will submit a sign in sheet with staff names and signature as well as a copy of training materials to CCLD via email by 9/14/22
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Licensee did not ensure that staff had the knowledge and skill required to provide necessary care and supervision for R1. Facility staff were not able to provide the care to assist R1 off the floor after experiencing a fall resulting in R1 laying on the floor for multiple hours.
This poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/14/2022
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
This requirement was not met as evidenced by:
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Facility has agreed to provide training of Personal Rights to all staff. A copy of a sign in sheet and training materials used will be provided to CCLD via email by 9/14/22.
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Licensee did not ensure R1's personal rights were met. Facility did not contact and report to R1's Representative that R1 had fallen, the status of R1's condition or that staff were unable to assist R1 off the floor.

This posis a potential health, safety or personal rights risk to persons 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4