157209377-2-12-2024-24-AS-SMOA-D32M4U-20240304081715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209377
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:10:39 AM

Unsubstantiated

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
01/11/2024 and conducted by Evaluator Mai Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240111123635

FACILITY NAME:	BURLINGTON, THE		FACILITY NUMBER:	157209377
ADMINISTRATOR:	GIBSON, KALA		FACILITY TYPE:	740
ADDRESS:	13 SYCAMORE DR		TELEPHONE:	(415) 810-0145
CITY:	WOFFORD HEIGHTS	STATE: CA	ZIP CODE:	93285
CAPACITY:	21	CENSUS: 16	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Ashley Bell, Facility Manager		TIME COMPLETED:	09:23 AM

ALLEGATION(S):

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Resident was inappropriately touched while in care.
Staff did not provide adequate food service to a resident.
Staff do not prevent the residents from being mistreated while in care.

INVESTIGATION FINDINGS:

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On 02/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit and met with Facility Manager Ashley Bell. Administrator Kala Gibson was called and unable to attend meeting.

During the course of the investigation, interviews were conducted, records were reviewed, and facility was toured. Adequate perishable foods were observed in the facility walk in refrigerator and large freezer. Adequate nonperishable foods were observed in facility walk-in pantry. The facility menu consists of a variety of food choices. Allegations resident was inappropriately touched while in care and staff do not prevent the residents from being mistreated while in care, although these allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, based on the interviews conducted, observation, and records reviewed, the above allegations are found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided via email to Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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