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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:59:50 AM

Document Has Been Signed on 07/23/2024 11:59 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:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Blanca Chavez - house managerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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07/22/2024 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with house manager Blanca Chavez. LPA contacted licensee Nora Serrano and obtained permission to meet with Ms. Chavez in Ms. Serrano's absence. Today’s visit is regarding an incident that occurred on 04/13/2024 and was reported to licensing on 04/15/2024.

It was reported that on April 13, 2024 8:15am staff discovered Client 1 (C1) on the floor by their recliner in the living room. No staff witnessed the fall, but Client 2 (C2) said that C1 fell and hurt their face on the end table. Staff examined C1's head and did not see any bruising, swelling, or bleeding at the time. Later in the evening staff noticed some bruising and swelling had occurred to C1’s head. Staff applied ice to bring down the swelling, but staff stated it didn't help much. On April 15, 2024 7:00am, assistant administrator arrived on duty and was told what happened to C1. Assistant administrator instructed staff to take C1 to the ER. C1 was transported to ER at 8:30am.

During the course of the investigation, it was learned that staff did not transport C1 to the ER after the fall and waited two days to seek medical attention for C1. C1 did not sustain any injury as a result of the fall.

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 Nora Chavez.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/23/2024 11:59 AM - It Cannot Be Edited


Created By: Rebecca Knight On 07/23/2024 at 11:28 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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
8075(a)

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80075 (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee agrees to conduct a training for all staff concerning the requirement to transport or arrange for transportation to the ER for medical observation after a fall with head strike. Licensee will provide LPA with training subject matter and sign in sheet with dates and staff signatures.
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Based on interviews and evidence obtained it was determined that staff waited two days to transport C1 to the ER to be examined after a fall with a head strike in the facility. This 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 08/06/2024.

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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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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