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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700212
Report Date: 10/28/2022
Date Signed: 10/28/2022 06:13:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221028101128
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: 6DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Carmen Balint, Administrator TIME COMPLETED:
06:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff working at facility
Facility not providing night supervision
Facility not providing care and supervision to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct 10-day inspection. LPA met with Paulette Barnett, caregiver, who contacted Administrator, Carmen Balint, who arrived at approximately 1:30 pm. LPA observed a second caregiver, Tiffany Phillips, washing dishes in the kitchen. LPA observed (3) residents to be watching television in the common area. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was wearing a surgical mask. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community.

During today's inspection, LPA interviewed Administrator, (5) residents, a family member of resident a resident (R1) and a nurse who provides care to resident (R1). LPA also reviewed all (6) resident binders, (2) staff binders and (2) Administrator binders. LPA observed all files to be organized and contain up to date documentation, including for trainings.

The results of the investigation are as follows:
cont on 9099C(1)..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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 6
Control Number 25-AS-20221028101128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
VISIT DATE: 10/28/2022
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
9099C(1). Allegation: Uncleared staff working at facility.

LPA reviewed Department records confirming (2) Administrators and staff (S1) who was working on 10/27/22 and today are cleared and associated to the facility. LPA reviewed documentation showing that staff (S2) had her fingerprints taken yesterday, 10/27/22, just prior to starting to work at the facility. Administrator stated that a fingerprint clearance has not been received yet for S2. LPA observed S2 working at the start of today's inspection.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Facility not providing night supervision.
Complaint states that on 10/28/22 at approximately 12:49 am, crew from the local fire department responded to a 9-1-1 call and entered the house, because no one responded by opening the front door. Crew was calling out throughout the facility searching for staff. Fire Crew finally was able to locate 2 staff (S1 and S2) sleeping in a room.

LPA interviewed residents (R1 and R2) who stated both stated that resident R1 needed assistance with toileting on 10/28/22 at approximately 12:45 am and was calling staff for help, but there appeared to be no one available to help R1. Administrator confirmed that she was at the facility on 10/27/22 until approximately 11:30 pm that day and had left shortly before R1 got up to use the restroom. Both R1 and R2 stated R1 had been calling for staff to assist for quite a while, approximately 15 minutes. The fire department crew had to enter through the back doors and window because no one answered the door. When fire department

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

cont on 9099C(2)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221028101128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
VISIT DATE: 10/28/2022
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
9099C(2).. Allegation: Facility not providing care and supervision to residents.

LPA interviewed residents (R1 and R2) who stated both stated that resident R1 needed assistance with toileting on 10/28/22 at approximately 12:45 am and was calling staff for help. Both residents also confirmed that resident R2 called 9-1-1 for assistance in helping R1 since there appeared to be no one else available to help R1. Administrator confirmed that she was at the facility on 10/27/22 until approximately 11:00 pm that day and had left shortly before R1 got up to use the restroom. R1's family member stated that R1 has not been sleeping well since recently moving to the facility and also has a faint voice and staff may have not heard him asking for help. R2 stated R1 had been "screaming for help" to assist for quite a while, approximately 15 minutes, but staff were sleeping.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.


Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies and civil penalty is is cited on the 9099 page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20221028101128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
87412(a)(13)(B)
1
2
3
4
5
6
7
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:
(B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LIcensee/Administrator already requested that staff S2 complete her fingerprints. Licensee/Admin is waiting for the results and will forward them to us when you.

Licensee/Administrator agree to read Regulation 87412 and submit a statement of understanding to the Department by 10/31/2022.
8
9
10
11
12
13
14
Based on documentation reviewed and interviews conducted, the LIcensee did not ensure that staff (S2) was fingerprint cleared and associated to the facility, prior to beginning to work, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
10/31/2022
Section Cited
CCR
87415(a)(1)
1
2
3
4
5
6
7
87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency.This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee/Administrator agree to move the call light system and place it in the caregiver room and also instruct residents to call the caregiver for help instead of 9-1-1.

Documentation that call light system/monitor has been moved to caregiver's room by 10/31/2022.
8
9
10
11
12
13
14
Based on interviews conducted, the LIcensee did not ensure that there was staff that was awake or on call, and able to respond to resident's (R1) call for assistance, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20221028101128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agree to move the call light system and place it in the caregiver room and also instruct residents to call the caregiver for help instead of 9-1-1.

Documentation that call light system/monitor has been moved to caregiver's room by 10/31/2022.
8
9
10
11
12
13
14
Based on interviews conducted, the Licensee did not ensure that staff provided assistance to resident (R1) on 10/28/22 at approximately 12:45 am, when he called for assistance in the bathroom, which posed an immediate health and safety risk to residents in care.
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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6