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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209374
Report Date: 01/26/2026
Date Signed: 01/26/2026 12:09:06 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
11/19/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20251119202642
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: 67DATE:
01/26/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Assistant Administrator Alena LemaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not properly supervising resident who is a fall risk.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings. LPA met with Assistant Administrator Alena Lema.


LPA interviewed staff. LPA reviewed records. LPA observed photos.


Based on interviews and photos and records review, facility staff were not properly supervising R1. Photos reveal R1 with half bedrails and another postural support/restraint near the bottom end of the bed with large pillows and a tv tray in between the bedrails and the additional postural support/restraint in attempt to prevent R1 from getting out of bed due to R1 being a high fall risk. Based on records review, there was no doctor perscription for R1 for restraints or postural supports. Facility has a plan for low/moderate fall risk residents, but does not have a plan for high risk fall residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
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 5
Control Number 24-AS-20251119202642
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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374
VISIT DATE: 01/26/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on photos, interviews and records review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, is being cited on the attached LIC 9099D.


A copy of this report with appeal rights and plan of correction was provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/19/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20251119202642

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: 67DATE:
01/26/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Assistant Administrator Alena LemaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility retained resident who requires a higher level of care.
Facility does not have adequate staffing to meet the needs of the residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings. LPA met with Assistant Administrator Alena Lema.

LPA interview staff and reviewed records.

Based on records review and interviews, it is undetermined if R1 required a higher level of care. Records review indicated R1 was previously at a Skilled Nursing Facility prior to being admitted to this facility. Based on interviews, Administrator stated the facility could meet R1’s needs and R1 did not require a higher level of care. R1 moved from this facility to another assisted living facility and not into a higher level of care.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20251119202642
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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374
VISIT DATE: 01/26/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews and records review, it is undetermined if facility had enough staff to meet the needs of residents. Based on interviews, Administrator was holding staff over to work longer shifts to meet the needs of R1. Based on records review, Administrator did not have an accurate staff schedule available to review. Administrator provided daily time clock logs of all staff, where LPA was unable to determine which staff were care staff.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.


A copy of this report was provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20251119202642
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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2026
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7

87464 Basic Services (f) 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). This requirement was not met
1
2
3
4
5
6
7

Licensee agrees to submit a date the plan will be completed and when training will be conducted by POC due date 01/27/26. Licensee agrees to submit the plan in writing for high risk fall residents and a copy of staff trained and training after training is conducted.
8
9
10
11
12
13
14
as evidenced by: Licensee did not provide care and supervision for R1 who is a high fall risk, by using postural supports/restraints, which were not perscribed by a doctor to keep R1 in bed which poses an immediate health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5