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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700344
Report Date: 06/24/2021
Date Signed: 06/24/2021 11:12:30 AM



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
04/27/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210427165529
FACILITY NAME:AUBURN VALLEY SENIOR LIVINGFACILITY NUMBER:
312700344
ADMINISTRATOR:CIRIC, ADINAFACILITY TYPE:
740
ADDRESS:3800 LORAY LANETELEPHONE:
(530) 388-6065
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:6CENSUS: 6DATE:
06/24/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Adina CiricTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident is denied visitors
Resident is denied phone calls
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Thursday June 24, 2021 to conclude the investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screen prior to entering the facility by staff.

Throughout the course of the investigation, the Department reviewed R1's physicians report, nursing notes, and care plan. LPA toured the facility and outside visitiation area. Additionally resident, relevant party and staff interviews were conducted. Based on the information obtained, the Department has concluded that the above allegations to be unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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 2
Control Number 25-AS-20210427165529
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: AUBURN VALLEY SENIOR LIVING
FACILITY NUMBER: 312700344
VISIT DATE: 06/24/2021
NARRATIVE
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The Department finds the allegations of resident being denied visitors and phone calls to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Appeal rights were printed and given. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2