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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 03/12/2026
Date Signed: 03/16/2026 11:44:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
12/22/2025 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20251222084031
FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:TYLER BRANESFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:88CENSUS: 71DATE:
03/12/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Director, Brenda VelasquezTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide proper diapering assiatnce to resident in care resulting in a rash
Staff did shower resient in care
Staff did not wash resident's clothing
Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Business Office Director, Brenda Velasquez, and explained the purpose of today's visit.

Regarding the allegation that staff did not provide proper diapering assistance to the resident resulting in a rash, LPA conducted interviews with staff and reviewed Resident 1’s records. LPA interviewed staff 1 who reported Resident 1 required assistance with incontinence care and stated staff routinely changed the resident throughout the shift. Staff 1 reported staff would change the resident multiple times per shift due to urinary incontinence. LPA interviewed staff 2 who reported staff have access to Resident 1’s care plans and are informed of all facility residents’ care needs at the beginning of their shifts. Staff 2 stated staff follow residents’ care plans and provide assistance with toileting and hygiene as needed. LPA interviewed staff 3 who reported they were Resident 1’s primary caregiver during PM shifts. Staff 3 reported the resident required assistance with toileting and dressing and stated they routinely checked the resident approximately three to four times per shift.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
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 2
Control Number 24-AS-20251222084031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MADONNA GARDENS
FACILITY NUMBER: 275202569
VISIT DATE: 03/12/2026
NARRATIVE
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Staff 3 reported Resident 1 required at least two brief changes per shift due to urinary incontinence and occasionally required clothing changes when urine leaked through clothing. Staff 3 further stated Resident 1 experienced a period where more frequent incontinent checks were required, during which staff provided additional hygiene care including showers and clothing changes. Staff reported residents are routinely checked by caregivers because many residents are unable to effectively communicate their needs. Staff reported they did not believe any resident sits in urine movements for extended periods and stated staff would change residents when they are observed to be soiled. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to provide proper diapering assistance to the resident. Therefore, the allegation is Unsubstantiated.


Regarding the allegation that staff did not shower the resident, LPA conducted interviews with facility staff and reviewed the resident’s records. Staff reported residents receive showers according to their care plans and staff assist residents with bathing as needed. Staff reported the Resident 1’s care plan included scheduled showers and staff provided showers in accordance with the resident’s needs. Staff 3 reported Resident 1 occasionally experienced incontinent accidents and during those instances staff would shower the resident and change their clothing to maintain hygiene and prevent skin irritation. Staff reported Resident 1 may have received additional showers when hygiene needs required it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.


Regarding the allegation that staff failed to wash the residents’ clothing, LPA conducted interviews with facility staff. Staff reported residents have designated laundry schedules and staff complete laundry services for residents according to the facility’s procedures. Staff stated Resident 1’s clothing was washed as needed and clothing was changed when the resident experienced incontinence episodes. Staff 3 reported Resident 1 occasionally required clothing changes due to urinary incontinence and staff would change the resident’s clothing and ensure the clothing was laundered as needed. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to wash the residents’ clothing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation that staff failed to safeguard the resident’s personal belongings, LPA conducted interviews with facility staff. Staff reported Resident 1’s personal belongings are maintained in Resident 1’s rooms and staff assist residents with laundry and clothing changes as needed. Staff did not report any concerns regarding missing personal items belonging to Resident 1. Staff 4 stated the facility did attempt to address Reporting Parties concern by purchasing new items for Resident 1 even though there was not any evidence that items were actually lost. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to safeguard the residents personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit Interview conducted with Business Office Director, Brenda Velasquez, and a copy of this report provided.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2