157209103-5-22-2025-24-AS-SPIY-DK5TE9-20250801143934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209103
Report Date: 05/21/2025
Date Signed: 05/22/2025 02:49:09 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
02/21/2025 and conducted by Evaluator Rachel A Bruce

COMPLAINT CONTROL NUMBER: 24-AS-20250221090844

FACILITY NAME:	AAA RESIDENTIAL ELDERLY RETREAT		FACILITY NUMBER:	157209103
ADMINISTRATOR:	BELL, ALEXIS E		FACILITY TYPE:	740
ADDRESS:	4313 MONITOR STREET		TELEPHONE:	(661) 213-6798
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS:	DATE:	05/21/2025
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Latecha Thompson, Caregiver		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not ensure facility plumbing was in good repair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/21/2025, Licensing Program Analyst (LPA) conducted unannounced inspection and met with Latecha Thompson, Caregiver. The purpose of the visit is to deliver findings on the above allegations.

During the course of this complaint investigation LPA conducted an inspecation, spoke with staff and residents, and obtained and/or reviewed facility records. Based on the investigation it was found that the facility did encounter a plumbing issue that was impactful to both staff and residents as the water was backed up and only one restroom was functional.

Based on LPAs observations and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy will be provided to the Administrator by email.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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-20250221090844

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: AAA RESIDENTIAL ELDERLY RETREAT	FACILITY NUMBER: 157209103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/21/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by plumbing issue which caused one toilet and kitchen sink to backup.	1 2 3 4 5 6 7	Facility has already remedied the issue and had the plumbing fixed. Plan of correction to be cleared as of today's visit.
	8 9 10 11 12 13 14	This poses a potential risk to the health and safety of the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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
02/21/2025 and conducted by Evaluator Rachel A Bruce

COMPLAINT CONTROL NUMBER: 24-AS-20250221090844

FACILITY NAME:	AAA RESIDENTIAL ELDERLY RETREAT		FACILITY NUMBER:	157209103
ADMINISTRATOR:	BELL, ALEXIS E		FACILITY TYPE:	740
ADDRESS:	4313 MONITOR STREET		TELEPHONE:	(661) 213-6798
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS:	DATE:	05/21/2025
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Latecha Thompson, Caregiver		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff left residents soiled for extended periods.
Staff did not maintain complete records for residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/21/2025 Licensing Program Analyst (LPA) conducted an unannounced inspection visit to the facility to deliver the investigative findings regarding the allegations listed above and described below.
The investigation included review of documentation, inspection of facility and interviews of both staff and residents. Allegation 1- Staff left residents soiled for extended periods. This was in reference to the night personnel who leave residents soiled through the night. LPA received conflicting information.
Allegation 2- Staff did not maintain complete information regarding Residents. This was in reference to Administrator allegedly changing information on daily records maintained by all staff. Review of the records did not provide conclusive evidence they were incomplete. LPA received conflicting information.
The Department has concluded the investigation regarding the allegations noted above. Based on the information received the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are found to be unsubstantiated.
An exit interview was conducted and a copy of the report and appeal rights will be provided to the Administrator via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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