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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208833
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:02:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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 Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240710081538
FACILITY NAME:TIMMERMAN D AND M FAMILY CARE HOMEFACILITY NUMBER:
547208833
ADMINISTRATOR:TIMMERMAN, DARRENFACILITY TYPE:
740
ADDRESS:22547 AVE 178TELEPHONE:
(559) 310-6202
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 4DATE:
07/15/2024
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Darren TimmermanTIME COMPLETED:
04:18 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered one resident's medication to another resident, resulting in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) L. Xiong conducted the subsequent complaint investigation visit to the facility.
During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The incident of staff administering one resident's (R1) medication to another resident (R2), resulting in hospitalizing of R2 did happened. Based on the 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 & Chapter number), are being cited on the attached LIC 9099D.”)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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 2
Control Number 24-AS-20240710081538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TIMMERMAN D AND M FAMILY CARE HOME
FACILITY NUMBER: 547208833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. LPA observed the incident of staff administering one resident's (R1) medication to another resident (R2), resulting in hospitalizing of R2 did occured.
1
2
3
4
5
6
7
Since the incident, training has been provided for staff to prevent future medication error. No further correction necessary.
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: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2