<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547201874
Report Date: 04/14/2021
Date Signed: 04/14/2021 06:41:45 PM

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
02/23/2021 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210223113014
FACILITY NAME:MERZOIAN RANCH LLC.FACILITY NUMBER:
547201874
ADMINISTRATOR:BOYD, RICHARD MFACILITY TYPE:
740
ADDRESS:21402 AVENUE 112TELEPHONE:
(559) 793-1786
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 6DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
05:09 PM
MET WITH:Courtney JanssonTIME COMPLETED:
05:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident wandered away from the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melind Medina conducted the subsequent complaint visit via telephone, due to Covid-19 pre-cautionary measures.

Based on the LPAs interviews, police reports, and documentation reviewed, R1 did leave facility without supervision. R1 was located by CHP then returned by Tulare County Sheriff Department when reported missing by facility. R1 was unharmed.

This complaint allegation is SUBSTANTIATED.

Deficiency cited on the 9099-D.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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-20210223113014
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: MERZOIAN RANCH LLC.
FACILITY NUMBER: 547201874
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2021
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
BASIC SERVICES: Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
1
2
3
4
5
6
7
Per Administrator Kimila Evans, R1 is redirected to backyard to smoke with staff present. Security camera has been installed in backyard for additional surviellance. Will submit written plan to document.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2