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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 052700992
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:53:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
04/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240408161123
FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 42DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angelica HarrymanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is odiferous
Facility is dirty
INVESTIGATION FINDINGS:
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On 4/15/24 at approximately 11:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open an investigation in to the above listed allegations. LPA Jensen met with Angelica White, Resident Care Director, and explained the purpose of today's visit.

During the course of the visit, LPA Jensen took the elevator down to the unit of the facility known as "Transitions". LPA Jensen detected an odor from the elevator. Once LPA Jensen arrived at the lower floor at Transitions, the odor was stronger. There was a definite discernable difference between the main lobby and the Transitions unit in terms of detectable odor. LPA Jensen interviewed the Resident Care Coordinator and the Maintenance Director who both confirmed that there is an odor on occassion likely eminating from a sewer pipe that connects with a bathroom on the lower level.

LPA Jensen inspected the carpets and observed and photographed in excess of 15 significantly sized stains in the carpeting on the lower level dining room and main level lobby dining room.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 3
Control Number 27-AS-20240408161123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 04/15/2024
NARRATIVE
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Based on LPA Jensen's observation of the dining room carpeting on the lower and main level, the allegation of "facility is dirty" is SUBSTANTIATED. Based on LPA Jensen's inspection of the facility lower level, and interviews conducted with facility staff, the allegation of "Facility is odiferous" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies for the stained carpets and for the malodorous nature of the facility are both being cited under the same regulatory section. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240408161123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The Licensee or Administrator will send a plan that addresses all areas of the stained carpeting and odor from the sewer line emanating in the lower level of the facility by 4/22/24 and will commence the work required to come in to compliance by 5/13/24.
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This requirement was not met based on LPA Jensen's observation of stained carpeting and observation that facility is malodorous. This poses a potential risk to the health, safety and personal rights of residents 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3