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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209377
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:42:10 AM

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
07/10/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240710163035
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: 18DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator Assistant Ashley Bell and Administrator Kala Gibson via telephoneTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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9
Staff member emotionally abuses residents in care.
INVESTIGATION FINDINGS:
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13
On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA.

During the course of the investigation, the department conduct interviews with residents. Interviews conducted confirmed, S1 called R1 inappropriate name and S1 spoke to residents with attitude. Based on interviews conducted, 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 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report and appeal rights was provided to the Administrator Assistant, whose signature confirms received of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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-20240710163035
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: BURLINGTON, THE
FACILITY NUMBER: 157209377
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2024
Section Cited
CCR
87468(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met:

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S1 shall have in-service training on personal rights. Training materials and proof of staff attendance shall be submitted to the department by POC due date 07/18/24.
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Based on interviews conducted, it was confirmed, S1 called R1 inappropriate names and did not speak to residents at the facility in an appropriate manner when approaching residents which poses an immediately health and safety and personal rights risk to the person in care.
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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: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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
07/10/2024 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240710163035

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: 18DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator Assistant Ashley Bell and Administrator Kala Gibson via telephoneTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member does not ensure that residents in care are administered their
medications according to physician's instructions.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an initial complaint inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Assistant (AA) Ashley Bell. Administrator Kala Gibson was called and stated unable to attend meeting. LPA delivered findings to AA.

During the course of the investigation, the Department conducted interviews, reviewed record, and audit medications. There was insufficient evidence to prove or disprove that staff did not administered residents’ their medication according to physician’s instructions. Therefore, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the Administrator Assistant, whose signature confirms received of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
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