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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209204
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:17:08 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
04/12/2024 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240412085152
FACILITY NAME:ANAYA ELDER CARE LLCFACILITY NUMBER:
247209204
ADMINISTRATOR:FERNANDEZ, DODERLEIN ANAYAFACILITY TYPE:
740
ADDRESS:2058 DANTE CTTELEPHONE:
(951) 772-9113
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:6CENSUS: 3DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator- Doderlein Anaya FernandezTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff left resident in a soiled diaper for an extended time.
Staff did not ensure resident had privacy.
INVESTIGATION FINDINGS:
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On 9/9/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA introduced herself and explained the reason for the visit. LPA met with Administrator (AD) Doderlein Anaya Fernandez.

1. The Department investigated the allegation: Staff left resident in a soiled diaper for an extended time. LPA conducted multiple interviews. During the interviews LPA was informed R1 was found on 4/10/24 with soiled brief and clothes, R1 also had bowel movement (BM) and was double briefed. On 4/11/24 R1 was found with dried BM & double briefed. LPA observed pictures provided which showed R1 with bowel movement going through the first brief to the second brief and with BM stuck to the buttocks of R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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-20240412085152
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: ANAYA ELDER CARE LLC
FACILITY NUMBER: 247209204
VISIT DATE: 09/09/2024
NARRATIVE
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2. The Department investigated the allegation: Staff did not ensure resident had privacy. LPA was informed during multiple interviews the administrator’s small child goes in and out of the resident’s rooms. On 4/16/24 LPA observed the small child going in and out of R2’s room during treatment of the roommate. LPA also observed the small child throwing a ball inside the facility which can be hazardous for resident’s using a walker, cane, or unbalanced.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter number 8, are being cited on the attached LIC 9099D.



Exit interview was conducted and a copy of this report LIC9099, LIC9099D, and appeal rights were provided to Administrator Doderlein Anaya Fernandez.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240412085152
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: ANAYA ELDER CARE LLC
FACILITY NUMBER: 247209204
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements-General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement is not met as evidenced by:
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Administrator will have proper training. AD will provide training verification.
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Based on observation, interview, & record review the licensee did not comply with the regulation listed above which poses a potential health, safety, or personal rights risk to residents in care. LPA conducted interviews and reviewed pictures which showed bowel movement in a double brief for R1. R1 was found by interviewees to have dried BM and smell of urine.
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Type B
09/23/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement is not met as evidenced by:
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Administrator will provide a statement regarding procedure put into place.
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Based on observation, interview, & record review the licensee did not comply with the regulation listed above which poses a potential health, safety, or personal rights risk to residents in care. LPA observed the Administrator's small child to go in and out of R2’s bedroom while the roommate was being treated. During interviews LPA was informed the small child was in and out of R1’s room while they were not properly dressed and being changed.
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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: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3