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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209374
Report Date: 08/28/2024
Date Signed: 08/28/2024 07:10:02 PM

Unsubstantiated


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
08/19/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240819102011
FACILITY NAME:GRAND OAKS ASSISTED LIVINGFACILITY NUMBER:
547209374
ADMINISTRATOR:SHELLHAMER, DAVIDFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:85CENSUS: 49DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, David Shellhamer
Residential Care Coordinator , Wendy Valdez 		TIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered the incorrect medication to residents in care.
Staff opened residents mail.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/28/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the required 10 day site visit. LPA was greeted by Administrator and Residential Care Services Coordinator, stated the purpose of the visit, and was allowed entry into the facility.

LPA conducted interviews and records review. Based on the information received, and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. No deficiencies cited. Exit interview conducted and copy of report was left with Administrator.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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