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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000700
Report Date: 01/27/2025
Date Signed: 01/27/2025 11:14:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240813163350
FACILITY NAME:COURTYARD AT LITTLE CHICO CREEK, THEFACILITY NUMBER:
045000700
ADMINISTRATOR:MORALES, MELISSAFACILITY TYPE:
740
ADDRESS:1770 HUMBOLDT ROADTELEPHONE:
(530) 342-0707
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:49CENSUS: 41DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator, Michelle Sans-CartierTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Questionable death.
INVESTIGATION FINDINGS:
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On January 27, 2025 at approximately 10:30 AM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Kayla Adkison arrived unannounced at Courtyard at Little Chico Inn, The for the purpose of delivering complaint findings. LPAs were greeted at the door by Assistant Administrator, Michelle Sans-Cartier, and was granted access into the facility.

Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Belman obtained and reviewed the Death Report from Butte County. LPA reviewed facility records. Resident could not be interviewed. LPAs toured the facility on January 27, 2025, and made observations.

Complaint alleges Questionable Death. Based on a review of the Death Report conducted by Investigator Belman, there was insufficient evidence to support the allegation. The resident was identified as being on Hospice and was cared for by the facility and the respective Hospice Agency. A review of the Hospice Care Records indicate that the resident was receiving comfort care and received continuous checkup hospice care visits. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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 59-AS-20240813163350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
VISIT DATE: 01/27/2025
NARRATIVE
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Furthermore, Investigator Belman reviewed a Hospice Care Note dated for July 16, 2024 in which it states, “Great care all needs well met.” LPA could not corroborate the allegation.

A finding that the complaint allegation of Questionable Death is unsubstantiated meaning that 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. Exit interview was conducted and a copy of this was report was signed and given to the Assistant Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240813163350

FACILITY NAME:COURTYARD AT LITTLE CHICO CREEK, THEFACILITY NUMBER:
045000700
ADMINISTRATOR:MORALES, MELISSAFACILITY TYPE:
740
ADDRESS:1770 HUMBOLDT ROADTELEPHONE:
(530) 342-0707
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:49CENSUS: 41DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator, Michelle Sans-CartierTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff mismanaged residents medication
INVESTIGATION FINDINGS:
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On January 27, 2025 at approximately 10:30 AM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Kayla Adkison arrived unannounced at Courtyard at Little Chico Inn, The for the purpose of delivering complaint findings. LPAs were greeted at the door by Assistant Administrator, Michelle Sans-Cartier, and was granted access into the facility.

During the investigation process, LPA reviewed facility records. Resident could not be interviewed. LPAs toured the facility on January 27, 2025 and made observations.

Complaint alleges Staff mismanaged residents’ medication. Based on a review of facility records, the preponderance of evidence standard has been met. LPA reviewed an incident report dated for August 9, 2024, which an employee exceeded as needed medication for the resident in care. The Hospice Agency doctor was notified of this medication error and the facility conducted an in-service training regarding medication management. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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 59-AS-20240813163350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
VISIT DATE: 01/27/2025
NARRATIVE
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Furthermore, LPA reviewed the Care Notes and learned that a staff member made a medication error which is documented on the Care Notes and signed by the Administrator on August 12, 2024 (See LIC 9099D). LPA educated the Assistant Administrator on the importance of ensuring that all residents are given proper dosages of medication as outlined in Title 22 Regulations and Physician Orders.

Deficiencies cited from the Health and Safety Code. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in Civil Penalties. Exit interview was conducted, and a copy of this report was signed and given to the Resident Services Director along with Appeal Rights.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240813163350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2025
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care:

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Licensee/Administrator shall conduct staff training and provide proof of that training to Community Care Licensing. In addition, Licensee/Administrator shall fill out an LIC 9098-Self-Certification understanding of the regulation. Licensee/Administrator shall also provide a statement on how future compliance will be met.
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Based on a review of an incident report dated for August 9, 2024, and Care Notes, the facility staff member did not administer the correct dosage of medication as outlined in the Physician Orders which presents a potential health, safety, and personal rights risk to the residents in care.
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POC due date: February 3, 2025.
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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: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5