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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 12/30/2024
Date Signed: 12/30/2024 11:41:07 AM

Document Has Been Signed on 12/30/2024 11:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PINE VILLE CARE HOMEFACILITY NUMBER:
045001436
ADMINISTRATOR/
DIRECTOR:		SERRANO,NORA CHAVEZFACILITY TYPE:
735
ADDRESS:1681 PINE STREETTELEPHONE:
(530) 533-1851
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 4DATE:
12/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Nora Serrano - licenseeTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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12/30/2024 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nora Serrano. The purpose of this visit was to deliver the results of a case management investigation.

On 12/05/2024 LPA received a complaint against the facility alleging that care home staff physically abused a resident. LPA conducted a complaint investigation and determined that the allegation is unfounded. However, LPA determined that a personal rights violation occurred.

It was learned that C1 came back to the facility and asked for money. Staff explained that C1 was not due to receive money until the following Friday. C1 started repeatedly asking for money. Staff stated they did not slap C1 but did place both of their hands on either side of C1’s face and “held C1’s face” attempting to calm C1. House manager stated they did not witness the encounter but did hear it from another room. Holding the client’s face is a personal rights violation.

Based on interviews, documents and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the 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 Nora Serrano.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/30/2024 11:41 AM - It Cannot Be Edited


Created By: Rebecca Knight On 12/30/2024 at 10:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PINE VILLE CARE HOME
FACILITY NUMBER: 045001436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2025
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse. This requirement is not met as evidenced by:
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Licensee agrees to conduct a staff training on the personal rights of clients to be free from corporal or unusual punishment which shall include methods staff can use to re-direct clients. Licensee agrees to submit training materials, subject matter, and staff sign in sheet to LPA by 01/13/2025 as proof of correction.
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Based on document review and interviews it was determined that S1 held C1's face which poses an immediate health and safety risk to clients in care.
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POC due 01/13/2025.

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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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