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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002776
Report Date: 07/16/2025
Date Signed: 07/16/2025 09:28:30 AM

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
04/07/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250407130042
FACILITY NAME:TRINITY PINESFACILITY NUMBER:
045002776
ADMINISTRATOR:CRYSTAL TORRESFACILITY TYPE:
772
ADDRESS:2753 WHITE AVENUETELEPHONE:
(530) 751-9900
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:16CENSUS: DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Crystal TorresTIME COMPLETED:
09:45 PM
ALLEGATION(S):
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Staff mishandled a client's medications while in care.
Staff did not follow a licensed physician's medical orders for a client.
INVESTIGATION FINDINGS:
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On 7-16-25, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 4-7-25. LPA Benson met with Administrator Crystal Torres, and explained the purpose of the visit.

During the interview process, 3 staff were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, MAR, admission agreement, physician report and progress notes.


Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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 2
Control Number 59-AS-20250407130042
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: TRINITY PINES
FACILITY NUMBER: 045002776
VISIT DATE: 07/16/2025
NARRATIVE
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Staff mishandled a client's medications while in care.

During the interview process staff reported the resident was given a new prescription when staff accompanied the resident to the doctor on 4-2-25. Staff reported a hold order until received was placed on 4-2-25 prescription. Staff stated a new report from the doctor was received on 4-3-25 to discontinue 4-2-25 medication orders as the lab results revealed the medication was resistant to infection. Staff reported a new medication order was received on 4-3-25. Staff reported the updated medication was received on 4-3-25 and the first dose given to the resident on 4-3-25 at 3:00 p.m.
Record review revealed a new prescription was recorded for the resident on 4-2-25 and placed on hold until available.Record review revealed that the 4-2-25 prescription was discontinued on 4-3-25 with a updated prescription called in on 4-3-25. Record review revealed that a new prescription was received on 4-3-25 with the first dose administered by staff to the resident on 4-3-25 at 3:00 p.m.

Staff did not follow a licensed physician's medical orders for a client.

The Administrator stated that it was brought to her attention that the residents mental health worker took the resident to the doctor on 4-7-25 without the staff’s knowledge. The administrator stated the mental health worker didn't take the Medication Administration Record, physician report and blood pressure records with the resident to the doctor’s visit. The administrator stated the staff always take a copy of the residents’ MAR, physician report and blood pressure records to doctor visits. Staff stated, when I took the client to the doctor on 4-2-25 I brought a copy of the clients MAR for the doctor. The administrator stated the resident was taken to the doctor for a follow up visit on 5-2-25, the doctor reported that someone brought the resident in for an appointment on 4-7-25 and didn't know the residents’ medications or if the last prescription was completed. During the interview process staff reported the resident was taken to the doctor’s office without our knowledge on 4-7-25 by their mental health worker with no MAR.

Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
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