045002440-11-1-2023-59-AS-KHOS-CY3KS7-20231130070902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002440
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:10:03 PM

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
09/29/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20230929132623

FACILITY NAME:	COUNTRY CREST ASSISTED LIVING		FACILITY NUMBER:	045002440
ADMINISTRATOR:	DAVIS, IRENE		FACILITY TYPE:	740
ADDRESS:	55 CONCORDIA LN		TELEPHONE:	(530) 533-7857
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	150	CENSUS: 64	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Irene Davis - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not following proper infection control requirements - UNSUBSTANTIATED
Staff left residents unattended - UNSUBSTANTIATED
Facility does not have sufficient emergency food supplies - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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11/01/2023 1:25 PM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with administrator Irene Davis. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation the Executive Director and 1 staff were interviewed.
The following documents were received and reviewed: staff list with telephone numbers, staff schedules for September 2023 for kitchen staff and memory care staff.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230929132623

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 CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
	VISIT DATE: 11/01/2023

NARRATIVE

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Staff are not following proper infection control requirements- UNSUBSTANTIATED

It was reported that kitchen staff do not use hair nets and do not wash their hands.

During an unannounced visit to the facility on 10/06/2023 LPA entered the vestibule that leads to the kitchen doors. LPA observed a sign on the door that reads "All employees must wash hands and wear a hair net. When entering the vestibule LPA observed a kitchen staff enter the kitchen, apply a hairnet and wash their hands, this staff person was unaware of LPA’s presence during this observation. LPA observed four staff working in the kitchen, all wearing hair nets.

Executive Director stated that California Department of Public Health received the same complaint because the facility prepares meals for their skilled nursing facility. CDPH investigated the same allegations. The only citation they issued was for a mislabeled box, no other citations were issued.

This allegation is unsubstantiated.

Staff left residents unattended- UNSUBSTANTIATED

It was reported that there was a shortage of kitchen staff and memory care staff were assisting in the kitchen leaving the memory care unit unattended.

LPA reviewed the kitchen staffing schedule for the month of September 2023. On 9/24/2023 the schedule shows that one cook called out for the day and tended their resignation over the phone. On the same day a second cook walked out of the building at 7:30 AM without notice. The Dietary Services Manager came on shift after being notified. The Executive Director provided additional assistance.

LPA reviewed the memory care staffing schedule for the month of September 2023. On 9/24/3023 the schedule shows there was 1 med tech and 2 care staff on duty for the shift of 6:30 AM through 2:30 PM.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230929132623

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 CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
	VISIT DATE: 11/01/2023

NARRATIVE

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Executive Director stated the med techs were in the kitchen for approximately ½ hour the day the cook walked out. During this time there were 2 care staff in Memory Care. 1 care staff, 1 server and 1 med tech were in the kitchen. The med tech that was in the kitchen was readily available for meds and emergencies during that time. The Dietary Services Director was already on their way and arrived approximately 30 minutes after the cook left.

It was determined that there were two care staff in the Memory Care unit while the med techs were assisting for 30 minutes in the kitchen due to the short-term staffing shortage. This allegation is unsubstantiated.

Facility does not have sufficient emergency food supplies - UNSUBSTANTIATED

During an unannounced visit to the facility on 10/06/2023 LPA observed an ample supply of non-perishable foods in the kitchen pantry. 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 Irene Davis.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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