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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000700
Report Date: 12/19/2022
Date Signed: 12/20/2022 08:49:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221020163655
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: DATE:
12/19/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Melissa Morales - administratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not safeguard resident’s incident report – SUBSTANTIATED

INVESTIGATION FINDINGS:
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12/19/2022 2:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Melissa Morales. The purpose of this visit was to deliver complaint investigation findings. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.
During the course of the investigation the administrator, 9 residents and 6 staff were interviewed. LPA obtained the following documents to investigate the above allegations: Related incident reports, staff list with telephone numbers, resident list, staff training on resident personal rights, physicians report, admission agreement, care plan.

Continued on LIC812-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
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 6
Control Number 25-AS-20221020163655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
VISIT DATE: 12/19/2022
NARRATIVE
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Staff did not safeguard resident’s incident report - SUBSTANTIATED

LPA reviewed 3 internal incident reports dated 10/02/2022,10/03/22, and 10/07/2022. In the reports dated 10/02/2022 and 10/03/2022 R1 was found on the floor next to their recliner. The report dated 10/07/2022 did not specify where R1 was found other than “on the floor.” None of these unwitnessed falls were reported to licensing.

During staff interviews 1 of 6 staff stated that the incidents were reported to the manager. 5 staff stated they did not know if the incident was reported.

Administrator stated If residents are OK with no injuries and they don’t go to the hospital then we just do an internal report. We have a report on 10/03/22 that R1 fell out of their recliner. The family said EMTs were not needed so R1 was not sent out. Any time the EMTs assess R1 and say R1 doesn’t need to go out to the hospital we don’t report it. Staff hand fills out a report, it is given to me, and then I decide if it needs to be reported to CCLD. They are trained on the process.

It was determined that staff are reporting incidents via internal report to the administrator. If the resident does not go out to the hospital the report is not being sent to CCLD. The facility needs improvement on their incident reporting process and the requirement to report to CCLD therefore this allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Melissa Morales.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221020163655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
87211(1)(d)
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87211(1)(d) Reporting Requirements – Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:
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Administrator agrees to review regulation 87211 and submit a statement of understanding.
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Based on LPA interviews and records review it was determined that that staff are reporting incidents via internal report to the administrator. If the resident does not go out to the hospital the report is not being sent to CCLD which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 1/03/2023.
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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.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221020163655

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: DATE:
12/19/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Melissa Morales - administratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident fell due to staff not making sure resident was in bed properly – UNSUBSTANTIATED
Staff did not assist resident in a timely manner - UNSUBSTANTIATED
Staff left residents in soiled diapers for an extended period of time- UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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12/19/2022 2:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Melissa Morales. The purpose of this visit was to deliver complaint investigation findings. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.
During the course of the investigation the administrator, 9 residents and 6 staff were interviewed. LPA obtained the following documents to investigate the above allegations: Related incident reports, staff list with telephone numbers, resident list, staff training on resident personal rights, physicians report, admission agreement, care plan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20221020163655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
VISIT DATE: 12/19/2022
NARRATIVE
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Page 2

Resident fell due to staff not making sure resident was in bed properly - UNSUBSTANTIATED

LPA reviewed 3 internal incident reports dated 10/02/2022,10/03/22, and 10/07/2022. In the reports dated 10/02/2022 and 10/03/2022 R1 was found on the floor next to their recliner. The report dated 10/07/2022 did not specify where R1 was found other than “on the floor.” There were no injuries reported on these incident reports. Review of R1’s Level of Care form dated 02/07/2022 states under the Mobility intervention section that R1 needs occasional in-room supervision.

9 of 9 residents interviewed stated they had not heard of a resident falling out of their bed.

During staff interviews 3 of 6 staff stated they had heard that R1 had fallen out of their recliner, not their bed. No staff interviewed had witnessed R1 fall out of their recliner or bed.

Administrator stated R1 has onset dementia and can ambulate independently. There was a period where R1 had a UTI and started talking and moving. R1 was getting up for no reason. When going to bed R1 sits on the side of the bed and turns to their side which puts them in the middle of the bed. R1 is not left hanging off the bed and is not bed bound. R1 doesn’t get up without staff guidance but when R1 had a UTI they became active.

It was determined that R1 was diagnosed with a UTI which made R1 more active than usual and the administrator and staff were aware that R1 was more active. As a result, on 10/02/2022 and 10/03.2022 R1 fell out of their recliner, and on 10/07/2022 R1 was found on the floor. There is no evidence that R1 fell out of their bed but R1 did fall out of their recliner twice and was found on the floor once. LPA recommends that the facility re-evaluate R1’s mobility supervision needs. This allegation is unsubstantiated.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20221020163655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700
VISIT DATE: 12/19/2022
NARRATIVE
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Page 3
Staff did not assist resident in a timely manner - UNSUBSTANTIATED

During staff interviews 5 of 6 staff stated they didn’t know how long it took staff to respond to R1 after they fell. 1 staff stated they completed their rounds at 10:00 PM and R1 was found on the floor at 10:30 PM. It is unknown what time R1 fell.

Administrator stated We check the residents every 2 hours but R1 keeps their door open and you can see them from the door. Staff puts R1 to bed about 9:00 PM and then checks on R1 every 2 hours. Administrator stated that R1 does wear a fall detector pendant.

It was determined that staff completed nightly rounds at 10:00 PM and checked R1 at 10:30 PM which is an acceptable amount of time between checks. This allegation is unsubstantiated.

Staff left residents in soiled diapers for an extended period of time - UNSUBSTANTIATED

8 of 9 residents stated they had not heard of or experienced staff leaving residents in soiled briefs. 1 resident had trouble hearing the question during their interview and did not answer.

During staff interviews 3 of 6 staff stated that residents were not left in soiled diapers during their specific shift. 2 of 6 staff stated they had heard that staff left residents in soiled diapers for an extended period of time but had not witnessed this. 1 staff stated they had never heard anything about this.

Administrator stated We had a resident who didn’t like to be changed by male staff and would wait for a female staff. It’s her right to not have a male change her if she doesn’t want to.

It was determined that staff are changing resident’s soiled briefs in an acceptable amount of time and residents are not waiting an extended period of time to be changed. This allegation is unsubstantiated.

No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Melissa Morales.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6