312700076-9-24-2020-27-AS-TORZ-BU72YD-20201007174834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700076
Report Date: 09/24/2020
Date Signed: 09/24/2020 10:58:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/23/2020 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 27-AS-20200423110606

FACILITY NAME:	PINES, THE		FACILITY NUMBER:	312700076
ADMINISTRATOR:	ROBERTSON, JOHN		FACILITY TYPE:	740
ADDRESS:	500 W RANCH VIEW DR		TELEPHONE:	(916) 672-5019
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	142	CENSUS: 100	DATE:	09/24/2020
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	John Robertson		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff did not follow Dr. orders

Staff did not document changes in resident's condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via telephone to deliver complaint findings for the following allegation(s): Staff did not follow Dr. orders; and Staff did not document changes in resident's condition. Findings are delivered via telephone due to COVID-19 and precautionary measures. LPA discussed the purpose of the call and the elements of the allegations with General Manager (GM)

Community Care Licensing (CCL) received allegations stating; Staff did not follow Dr. orders; and Staff did not document changes in resident's condition. During the course of the investigation LPA conducted interviews, reviewed former resident’s file from the facility, medical records from an outside agency working with the resident, and records from the complainant. LPA unable to interview the former resident.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020

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 27-AS-20200423110606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700076
	VISIT DATE: 09/24/2020

NARRATIVE

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The resident was prescribed oxygen on an as needed basis. Medical records from the outside agency show the resident was using oxygen during several visits and not using oxygen during visits. When the resident was not using the oxygen, the notes did not indicate the resident was in any distress. The orders for the resident stated the outside agency was responsible for monitoring oxygen use and the facility staff were responsible for custodial care for the resident and to notify the agency of any changes of condition. There are no instructions on what the signs are for someone suffering from shortness of breath in the resident’s file. There are notes from the agency and the facility showing communication between them regarding the resident’s condition. Witness stated they saw the resident cough and appeared to be in distress during visits. The visits were restricted due to COVID 19 precautions and the visitors were outside and spoke to the resident through a window. Staff were not present during the visits. They would set it up, and then do random checks during the visit to allow for privacy. There are no notes from staff showing the resident was in distress or the visitors telling the staff the resident was in distress. Allegation cannot be proved or disproved due to each side having their own version of events.

Facility records documentation showed progress notes with a gap with nothing noted for 23 days. The facility did submit some notes completed by an outside agency dated in between the 23 days. GM stated the facility staff will actively chart a few days after a resident moves in and then will taper off after the resident settles in. GM stated the facility staff only chart when changes in condition are noted thereafter. His statement does match what the charting reflects. LPA also obtained medical records from the outside agency working with the resident during this period and there were continuous notes about the resident. The notes did not indicate any changes in the resident’s condition during this time.

Based on the above, all allegations cannot be proved or disproved therefore they are unsubstantiated.

LPA signed the electronic copy. LPA is going to email a copy of this report to Licensee. Licensee is to print, review, sign, and email a signed copy back to LPA

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2020

LIC9099 (FAS) - (06/04)

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