<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 052700992
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:27:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2023 and conducted by Evaluator Jennifer Fain
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230612130714
FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:BITLER, MAUREEN H.FACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 51DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amgelica WhiteTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure an adequate supply of PPE for staff to provide care to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6-16-23 at approximately 9:30am, Licensing Program Analyst (LPA) Jennifer Fain and Lisensing Program Manager Liza King arrived unannounced to open and investigate a complaint for the allegation noted above. LPA Fain and LPM King met with Resident Care Director (RCD) Angelica White and explained the purpose of the visit. LPA and LPM interviewed RCD, staff1 (S1), S2, and S3. LPA and LPM also conducted facility observation and requested Staff and Resident Rosters to be emailed to Kimberly.Viarella@dss.ca.gov by 6/19/23.

Allegation #1: Licensee does not ensure an adequate supply of PPE for staff to provide care to residents. LPA conducted interviews, RCD and S1 confirmed process for aquiring gloves. LPA observed gloves present in the standard location, approximately 2 cases of gloves in RCD's ofice and approximately 2 cases of gloves in Emergency PPE Supply. Based on observation and interviews with RCD and S1 it was determined that an adequate supply of gloves was available for resident care. As a result, there is a preponderance of evidence to conclude faclity is in compliance, therefore, this allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2023 and conducted by Evaluator Jennifer Fain
COMPLAINT CONTROL NUMBER: 27-AS-20230612130714

FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:BITLER, MAUREEN H.FACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 51DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amgelica WhiteTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing adequate food services to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6-16-23 at approximately 9:30am, Licensing Program Analyst (LPA) Jennifer Fain and Lisensing Program Manager Liza King arrived unannounced to open and investigate a complaint for the allegation noted above. LPA Fain and LPM King met with Resident Care Director (RCD) Angelica White and explained the purpose of the visit. LPA and LPM interviewed RCD, staff1 (S1), S2, and S3.

Allegation #1: Staff are not providing adequate food services to residents. LPA and LPM conducted interviews and facility observation. LPA and LPM observed the two kitchen areas in Memory Care (MC) and Assisted Living main kitchen. One MC kitchen was observed to have a steam tray for maintaining food temprature, the second memory care kitchen did not have a steam table. Interviews with RCD, S2 and S3 confirmed that food traveled from the Facility kitchen to the MC resident dining areas without temprature control.
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230612130714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 06/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
S2 and S3 reported that the food arrives to the MC via a cart with no temperature control, S3 stated a hot box for food transfer had been requested on more than one occasion. S2 stated that the temperature of the food is not checked upon arrival to the MC kitchen areas nor before it is served to the residents. RCD stated that not all residents arrive for meals immediately. As a result, there is a preponderance of evidence to conclude the facility does not provide adequate food services to residents, therefore, this allegation is SUBSTANTIATED

As a result of this investigation, citations are issued under Title 22, Division 6. An exit interview was conducted with Angelica White and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230612130714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87555(b)(9)
1
2
3
4
5
6
7
General Food Service-The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will implement a procedure to ensure food maintains its temperature through transport from the kitchen to the MC dining areas and upon service. Plan to be submitted to Kimberly.Viarella@dss.ca.gov.
8
9
10
11
12
13
14
Based on interviews and observations the licensee failed to implement a procedure to ensure the proper temperature of food is maintained during transport and prior to service.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5