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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002620
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:46:59 AM


Document Has Been Signed on 09/15/2022 10:46 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:INN AT THE TERRACES, THEFACILITY NUMBER:
045002620
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2950 SIERRA SUNRISE TERRACETELEPHONE:
(530) 894-5429
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:99CENSUS: 81DATE:
09/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Cliff KeeneTIME COMPLETED:
11:30 AM
NARRATIVE
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On 09/15/2022 at 930 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management related to a complaint investigation 25-AS-20220330164722. LPA met with Executive Director/Administrator Cliff Keene and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and 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: N-95 Mask

During the course of complaint investigation 25-AS-20220330164722, in which there are substantiated allegations: Resident sustained serious injuries due to a lack of care and supervision and Staff neglected to seek timely medical attention for resident, additional deficiencies were discovered.

During the course of the investigation, the Department found staff were falsifying information on the Resident Meal Checklist. Staff were checking off that residents had been in attendance during meals when they had not been. Due to falsifying the information on the resident meal checklist on 3/21/2022, a resident’s fall and injury went undetected. The facility’s policy was that residents who did not attend meals were to be checked on. The resident was not checked on when the resident did not attend meals on 3/21/2022. During interviews, staff indicated it was not clear who was responsible for checking on residents who did not show for meals. Staff indicated part of the confusion was related to being short staffed.

On 7/13/2022 the Department learned that the facility had key fob records to the resident’s door. The facility discovered on 3/22/2022, that there was no indication per the key fob records, that the resident had exited their room. The facility was aware there was an open complaint investigation on 04/08/2022 and did not disclose they had key fob records that indicated the resident was not checked on for at least 24 hours.

The following deficiencies were cited per Title 22 of the California Code of Regulation (809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 09/15/2022 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: INN AT THE TERRACES, THE
FACILITY NUMBER: 045002620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/16/2022
Section Cited

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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by: Based upon interview, observation and document review the Licensee failed to
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Licensee agrees to volunteer information that would be useful in an investigation. Licensee agrees to provide a letter stating this to CCLD no later than 9/16/2022
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ensure staff were accurately documenting the services provided to residents. The licensee did not volunteer key fob records but instead provided statements that were not supported by the key fob records.
This poses an immediate Health, Safety and/or Personal Rights risk to clients in care
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Request Denied
Type A
09/16/2022
Section Cited

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87205, Accountability of Licensee Governing Body states-(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Licensee agrees to institute a better audit process for policies in place. Licensee agrees to provide improved upon audit process to CCLD no later than 9/16/2022
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This requirement is not met as evidenced by: Based upon interview, observation and document review the Licensee failed to provide adequate oversight of staff to ensure compliance with policies and the welfare of individuals policies were intended to serve.
This poses an immediate Health, Safety and/or Personal Rights risk to clients in care
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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