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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700212
Report Date: 08/25/2020
Date Signed: 08/25/2020 01:59:01 PM



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
06/18/2020 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 27-AS-20200618160413
FACILITY NAME:ROCK CREEK SENIOR CAREFACILITY NUMBER:
312700212
ADMINISTRATOR:BALINT, PAVELFACILITY TYPE:
740
ADDRESS:6408 MENDEZ CREEK CTTELEPHONE:
(916) 899-6298
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 4DATE:
08/25/2020
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Carmen BalintTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility refusing to pick up resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via telephone to deliver complaint finding for the following allegation(s): Facility refusing to pick up resident's medication. Finding 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 Co-Administrator Carmenuta Balint.

LPA was unable to interview the former resident. Co-Administrator submitted to CCLD a copy of a pharmacy receipt showing the medications in question were paid for and picked up by the Co-Administrator. The receipt states a consulation was made when the medication was picked up.

Based on the paperwork and the interview and documentation, the allegation is unfounded. Due to the above noted information, we have found the complaint is Unfounded, meaning that the allegations are false, could not have happened and/ or is without reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
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-20200618160413
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: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
VISIT DATE: 08/25/2020
NARRATIVE
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 A copy of this report will be provided to the facility administrator via email. A copy will be sent to the facility via email and is to be signed and returned to Community Care Licensing Division.

Signature for facility representative shall be on the hard copy of this report.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
06/18/2020 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 27-AS-20200618160413

FACILITY NAME:ROCK CREEK SENIOR CAREFACILITY NUMBER:
312700212
ADMINISTRATOR:BALINT, PAVELFACILITY TYPE:
740
ADDRESS:6408 MENDEZ CREEK CTTELEPHONE:
(916) 899-6298
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 4DATE:
08/25/2020
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Carmen BalintTIME COMPLETED:
01:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not administering medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hiratsuka, contacted the facility via telephone to deliver complaint finding for the following allegation(s): Facility not administering medication as prescribed. Finding 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 Co-Administrator Carmenuta Balint.
LPA was unable to interview the former resident. Co-Administrator stated resident refused to take medications on a regular basis. LPA cannot prove or disprove either side because there are no other witnesses nor was LPA able to interview the former resident.
Allegation is unsubstantiated because LPA cannot prove or disprove the allegation.

A copy of this report will be provided to the facility administrator via email. A copy will be sent to the facility via email and is to be signed and returned to Community Care Licensing Division.
Signature for facility representative shall be on the hard copy of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3