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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209146
Report Date: 12/10/2024
Date Signed: 12/11/2024 08:06:13 AM

Unsubstantiated


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
10/16/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20241016102317
FACILITY NAME:QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
157209146
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2607 MT. VERNON AVENUETELEPHONE:
(661) 871-8133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 49DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Caregiver/Office Staff Jan Krizia AdajarTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not prevent resident from leaving the facility unassisted
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to deliver findings. LPA discussed the purpose of the visit and the elements of the allegations with Caregiver/Office Staff Jan Krizia Adajar. Administrator Nancy Cudal gave permission for Caregiver/Office Staff Jan Krizia Adajar to sign for this report.

LPA reviewed records and interviewed staff. LPA obtained copies of residents file, which was incomplete. Facility did not have a completed LIC 602 signed by a doctor. Facility has LIC 601 completed but not signed. Admissions agreement was signed, but was incomplete Pre Placement Appraisal was blank and Needs and Service Plan was blank. Centrally stored log was complete. Due to lack of documentation, LPA was unable to determine if R1 can leave facility unassisted.
Based on record reviews and interviews, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
A copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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
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
10/16/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20241016102317

FACILITY NAME:QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
157209146
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2607 MT. VERNON AVENUETELEPHONE:
(661) 871-8133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 49DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Caregiver/Office Staff Jan Krizia AdajarTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette (LPA) conducted a visit to deliver findings. LPA discussed the purpose of the visit and the elements of the allegations with Caregiver/Office Staff Jan Krizia Adajar. Administrator Nancy Cudal gave permission for Caregiver/Office Staff Jan Krizia Adajar to sign for this report.

LPA conducted interviews and reviewed records. R1 was not evicted, however it was determined R1 needed a higher level of care. LPA did not locate an eviction notice for R1 in R1's file.

Based on LPA's interviews and record review, this agency has investigated the complaint alleging, Illegal eviction. We have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.

An exit interview was conducted and a copy of this report was provided.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2