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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001608
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:14:43 PM

Substantiated


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
07/25/2023 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20230725165157
FACILITY NAME:COUNTRY HEARTSFACILITY NUMBER:
045001608
ADMINISTRATOR:LEONARD, CAROLFACILITY TYPE:
740
ADDRESS:7170 LOWER WYANDOTTE RD.TELEPHONE:
(530) 589-2466
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:15CENSUS: DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Natasha Leonard - administratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not follow reporting requirements. - SUBSTANTIATED
INVESTIGATION FINDINGS:
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08/30/2023 01:40 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Natasha Leonard. The purpose of this visit was to deliver complaint investigation results.

During the course of the investigation LPA interviewed administrator and staff. LPA reviewed the following documents: staff list with telephone numbers, resident list, admission agreement, responsible party information, and LIC602 Physicians report for 3 residents.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 59-AS-20230725165157
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: COUNTRY HEARTS
FACILITY NUMBER: 045001608
VISIT DATE: 08/30/2023
NARRATIVE
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Staff did not follow reporting requirements. – SUBSTANTIATED

It was reported that on 7/17/2023 Resident 1’s (R1) responsible party was notified by a local hospital that R1 had fallen and sustained an injury. The responsible party was not notified by the facility.

LPA review of R1’s Emergency Identification form revealed that R1 has a responsible party / POA assigned. Incident reports that were submitted to licensing on 7/11/23, 7/16/23 and 7/17/23 do not show any other agencies or the responsible party / POA were notified that R1 had fallen or that R1 had sustained an injury. These incident reports were submitted by Staff 1 and Staff 2.

Staff 1 and Staff 2 stated they did not call R1’s responsible party.

Administrator stated that Staff 1, and Staff 2 had notified R1’s responsible party.

It was determined that R1’s responsible party was not notified by facility staff or facility administrator that R1 had fallen or that R1 had sustained an injury on 07/17/2023. 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 Natasha Leonard.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230725165157
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: COUNTRY HEARTS
FACILITY NUMBER: 045001608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2023
Section Cited
CCR
87211
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87211 Reporting Requirements (a) 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... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:
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Administrator agrees to conduct staff training on the requirement to notify responsible party if a resident sustains a fall and/or is being treated for injury. Administrator will submit staff training sign in sheet as proof of correction.
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Based on LPA interviews and records review it was determined that staff did not notify Resident 1’s responsible party that R1 had fallen and was being treated at the hospital 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 9/13/2023.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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
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
07/25/2023 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20230725165157

FACILITY NAME:COUNTRY HEARTSFACILITY NUMBER:
045001608
ADMINISTRATOR:LEONARD, CAROLFACILITY TYPE:
740
ADDRESS:7170 LOWER WYANDOTTE RD.TELEPHONE:
(530) 589-2466
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:15CENSUS: DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Natasha Leonard - administratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident sustained a fractured hip while in care. - UNSUBSTANTIATED
Staff do not ensure floors are kept in safe, clean, sanitary conditions for residents in care. - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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08/30/2023 01:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Natasha Leonard. The purpose of this visit was to deliver complaint investigation results.

During the course of the investigation LPA interviewed administrator and staff. LPA reviewed the following documents: staff list with telephone numbers, resident list, admission agreement, responsible party information, and LIC602 Physicians report for 3 residents.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 59-AS-20230725165157
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: COUNTRY HEARTS
FACILITY NUMBER: 045001608
VISIT DATE: 08/30/2023
NARRATIVE
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Resident sustained a fractured hip while in care. - UNSUBSTANTIATED

LPA review of Resident 1’s (R1) admission agreement shows that R1 moved into the facility on May 26, 2023. Resident Appraisal form dated 5/26/23 lists physical disabilities of aphasia and speech issues, dementia. Social factors (likes and dislikes) are reading, walking , and watching TV. R1 ambulatory status – able to walk without any physical assistance. R1 did not require help with moving about the facility. R1’s Appraisal Needs and Services plan dated 5/26/23 shows functioning skills as active, needs minimal assistance at times. No assistive devices (walker / wheelchair). Able to dress self, groom self. R1’s Physicians Report shows that R1 was able to leave the facility unassisted. Ambulatory status is ambulatory.

Three incident reports were submitted related to R1. The first was submitted on 7/11/23 in which it was reported that R1 fell over some of their belongings and landed on their rear end in their bedroom. R1 was assessed for injury and denied having pain. On 7/16/23 R1 was found by staff on their knees in the common area. R1 stated they had slipped while leaving the room. Staff assessed R1 for injury, R1 stated they had minimal pain and adamantly refused to be taken to the ER when staff asked. R1 stated they did not need or want medical assistance. On 7/17/23 R1 stated they had increased pain in their knee. Staff left the room to get Tylenol for R1 and when they returned R1 was on their knees. R1 stated they had tried to stand but their knee hurt. EMS was called and R1 was transported to the ER.

Staff 1 stated that R1 had not fallen at all (previously) and it was all of the sudden. Staff 2 stated R1 was definitely not a fall risk.

Administrator stated that R1 was not considered a fall risk prior to the falls.

Although R1 did fracture their hip due to fall, there was not enough evidence to substantiate that the resident fell due to lack of supervision. R1 was not a known fall risk, R1 was ambulatory and able to leave the facility unassisted. After their initial fall on 7/11/2023 R1 denied having pain. On 7/16/2023 when R1 fell a second time, R1 refused to be transported the ER to be assessed and stated their pain was minimal. On 7/17/2023 R1 finally agreed to be transported the ER due to an increase in pain. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230725165157
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: COUNTRY HEARTS
FACILITY NUMBER: 045001608
VISIT DATE: 08/30/2023
NARRATIVE
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Staff do not ensure floors are kept in safe, clean, sanitary conditions for residents in care - UNSUBSTANTIATED

On 07/19/2023 LPA visited the facility and observed that the licensee was installing new flooring in the common areas. LPA did not observe the facility to be unclean or unsanitary during the visit.

Administrator stated they expected the floor installation to be completed soon.

It was determined that in the process of the laminate floor installation some items needed to be temporarily relocated to another section of the facility which is a normal and expected process when new floors are being installed. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to administrator Natasha Leonard.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6