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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209191
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:36:11 PM

Substantiated


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
05/21/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240521121651
FACILITY NAME:WESTCHESTER HOME ON SPRUCE, THEFACILITY NUMBER:
157209191
ADMINISTRATOR:KAUR, LAKHWINDERFACILITY TYPE:
740
ADDRESS:2485 SPRUCE STREETTELEPHONE:
(661) 633-1225
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:6CENSUS: 4DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sundae Hill, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff do not administer resident’s medications as prescribed
INVESTIGATION FINDINGS:
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On 12/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Anne Neri and staff Jacqueline tucker. Administrator Sundae Hill was called and arrived shortly. Complaint findings were delivered to Administrator.

During the course of the investigation, residents’ medications were audit and MARs were reviewed,
medications audit showed staff did not administered the residents’ medications as directed by physician.

Based on observation, the preponderance of evidence standard has been met, therefore, the above
allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6
are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal
rights were provided to the Administrator, whose signature on this form confirms receipt of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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 3
Control Number 24-AS-20240521121651
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: WESTCHESTER HOME ON SPRUCE, THE
FACILITY NUMBER: 157209191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation. Statement will include staff in-service trainings, steps on administering medications, review of medications. Statement will be submitted to Fresno CCL office by POC due date 12/12/24.



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Based on observation, records reviewed, and interview conducted, residents’ medications were checked, and medications were observed not administered as directed by physician by staff, which poses an immediate health, safety or personal rights risk to persons in care.
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Licensee shall have all staff in-service trainings on medications regulations. Licensee will submit documentation of training topics including training date, training materials, training instructor name, and staff attendance rooster to the Fresno CCL office by 12/27/24.
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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: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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
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
05/21/2024 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20240521121651

FACILITY NAME:WESTCHESTER HOME ON SPRUCE, THEFACILITY NUMBER:
157209191
ADMINISTRATOR:KAUR, LAKHWINDERFACILITY TYPE:
740
ADDRESS:2485 SPRUCE STREETTELEPHONE:
(661) 633-1225
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:6CENSUS: 4DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sundae Hill, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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8
9
Facility staff speak inappropriately to resident
Facility staff did not assist resident with feeding
INVESTIGATION FINDINGS:
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3
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5
6
7
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9
10
11
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13
On 12/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Anne Neri and staff Jacqueline tucker. Administrator Sundae Hill was called and arrived shortly. Complaint findings were delivered to Administrator.

During the course of the investigation, interviews were conducted with staff and residents. LPA conducted interviews with staffs and residents. Based on interviews conducted, it could not be proven or disproven that staff spoke in appropriately to resident and did not assist resident with feeding. Therefore, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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