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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:28:04 PM



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
08/11/2021 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210811111129
FACILITY NAME:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:BERKELEY, LORIFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Lori Berkeley, Executive DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained a fracture while in care
Resident requires a higher level of care
INVESTIGATION FINDINGS:
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On October 21, 2021, at 915:am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons and Licensing Program Manager, (LPM), Laura Munoz arrived unannounced to deliver findings for Complaint # 25-AS-20210708083425. LPA met with Lori Berekley, Executive Director and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocals, and a daily self-screening questionaire for sysptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and worn a mask for the Personal Protective Equipment (PPE). Additionally, LPA was screened by the front desk personnel upon arrival.

During the investigation it was learned that R1 had an unwitnessed fall in her room on 08/09/2021. The resident was assessed at the hospital and diagnosed with a fractured left femur. R1 had one previous fall on 07/31/2021 that resulted without injury. Based records review, R1 was non-ambulatory and was able to self ambulate in her wheelchair.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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-20210811111129
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: ANSEL PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 312700574
VISIT DATE: 10/21/2021
NARRATIVE
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Records further indicate that based on R1's previous fall, R1 was put on hour checks to ensure R1's safety. After R1's fall on 08/09/2021, it was determined at the hospital that R1 needed a higher level of care than what the facility could provide and R1 did not return to the facility.

The allegations are substantiated however, no citations are issued. The facility put hourly checks in place to monitor R1 and there is no evidence that R1's fracture was due to the negligence of the facility. In addition, once R1 was identified as needing a higher level of care, R1 was relocated.

An exit interview was conducted and a copy of this report was given to Lori Berkeley
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2