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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 167209143
Report Date: 09/06/2023
Date Signed: 09/07/2023 07:44:21 AM

Substantiated


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
08/31/2023 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230831152122
FACILITY NAME:SPARKS' RESIDENTIAL MEADOWBROOKFACILITY NUMBER:
167209143
ADMINISTRATOR:SPARKS, CEIARAFACILITY TYPE:
740
ADDRESS:983 S GREEN STREETTELEPHONE:
(559) 772-8385
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY:6CENSUS: 5DATE:
09/06/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Administrator, Ceiara SparksTIME COMPLETED:
12:41 PM
ALLEGATION(S):
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Facility is not operating within the license
INVESTIGATION FINDINGS:
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Licensing Program Analys (LPA) Darius Williams conducted an unannounced complaint visit. LPA Williams met with Administrator Ceiara Sparks and discussed the purpose of the visit.

LPA Williams toured facility, interviewed Administrator, and observed Resident 1(R1).

LPA Williams observed R1 in a wheel chair and a Gait belt around their torso. The Administrator reported the gait belt was used to transfer R1 from bed to the wheel chair. Administrator reported R1 can physicially walk, but R1 chooses not to.

Administrator asked R1 to stand up out of their wheel chair and R1 repeated between statements of, "I can walk and I can't walk". LPA Williams did not observe R1 stand during the visit.

*Continue on LIC 9099C*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
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 5
Control Number 24-AS-20230831152122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SPARKS' RESIDENTIAL MEADOWBROOK
FACILITY NUMBER: 167209143
VISIT DATE: 09/06/2023
NARRATIVE
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The Administrator will request a new medical examination for R1.

Additionally, a new fire clearance will be requested for non-ambulatory as the current fire clearance is for ambulatory only.

Based on LPAs observations and interviews, the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6,Chapter 8, section 87202(a)(1), is being cited on the attached LIC 9099D.

Plan of correction was discussed and reviewed with the Administrator.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20230831152122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SPARKS' RESIDENTIAL MEADOWBROOK
FACILITY NUMBER: 167209143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87202(a)(1)
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(a): ...prior to accepting or retaining any of the following types of persons,... and obtain an appropriate fire clearance... (1)Nonambulatory persons

This requirement was not met evident by:
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The Licensee agreed to submit a request for a nonambulatory fire clearance to the Department by 9/8/2023.

Additionally, the the Licensee will request a new medical examination for R1.
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Based on observation and record review, the Licensee did not obtain a nonamulatory fire clearance for 1 out of 6 person, which poses an immediate health and safety risk for persons 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: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/31/2023 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230831152122

FACILITY NAME:SPARKS' RESIDENTIAL MEADOWBROOKFACILITY NUMBER:
167209143
ADMINISTRATOR:SPARKS, CEIARAFACILITY TYPE:
740
ADDRESS:983 S GREEN STREETTELEPHONE:
(559) 772-8385
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY:6CENSUS: 5DATE:
09/06/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Administrator Ceiara SparksTIME COMPLETED:
12:41 PM
ALLEGATION(S):
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Staff did not ensure facility is pest free
INVESTIGATION FINDINGS:
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Licensing Program Analys (LPA) Darius Williams conducted an unannounced complaint visit. LPA Williams met with Administrator Ceiara Sparks and discussed the purpose of the visit.

LPA Williams toured the facility. LPA Williams did not smell any odors or observe any pests (bugs, mice, etc) in the facility or evidence of pests (such as droppings). The Administrator reported the outside of the facility is sprayed once a month.

This agency has investigated the complaint alleging staff did not ensure facility is pest free. 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 will be provided via e-mail.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5