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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209377
Report Date: 03/08/2024
Date Signed: 03/13/2024 03:12:51 PM

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
02/08/2024 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20240208091113
FACILITY NAME:BURLINGTON, THEFACILITY NUMBER:
157209377
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:13 SYCAMORE DRTELEPHONE:
(415) 810-0145
CITY:WOFFORD HEIGHTSSTATE: CAZIP CODE:
93285
CAPACITY:21CENSUS: 16DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Kala Gibson, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not safeguard residents cash
Facility did not provide assistance with residents medical care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/08/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA stated the purpose of the visit and met with Administrator Kala Gibson.

During the course of the investigation, LPA toured the facility, reviewed records, and conducted interviews. R1 and Administrator confirms R1 does not have cash store at the facility. Based on iinterview which were conducted, staff provides first aid and assists upon request by resident. Therefore, the preponderance of evidence standard has not been met, 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 report confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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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