312700574-7-28-2023-25-AS-KHOS-CUSHUL-20230817063032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:19:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Todd Tryon

COMPLAINT CONTROL NUMBER: 25-AS-20230104171718

FACILITY NAME:	ANSEL PARK SENIOR LIVING COMMUNITY		FACILITY NUMBER:	312700574
ADMINISTRATOR:	DEBORAH TAYLOR		FACILITY TYPE:	740
ADDRESS:	1200 ORCHID DRIVE		TELEPHONE:	(916) 250-0770
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	100	CENSUS: 82	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Deborah Taylor, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not keep resident's family appraised of resident's condition.
Facility staff did not ensure that resident's room thermostat was operable.
Resident's jewelry went missing while in care at the facility.
Facility staff did not ensure proper placement and use of resident's hearing aids.
Facility staff did not keep resident's room clean of fecal matter.
Facility staff did not meet resident's hygiene needs.
Facility staff did not assist residents while eating.
Facility staff did not meet resident's laundering needs.
Resident was made to sleep in urine stained bed sheets and mattress.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On July 28, 2023 LPA Tryon visited the facility to complete the complaint. LPA met with Executive Director Deborah Taylor.
During the course of the investigation LPA has toured the facility, reviewed documents, interviewed staff and interviewed witnesses.
Regarding the allegation that Facility staff did not keep resident's family appraised of resident's condition, LPA has interviewed staff and witnesses. LPA learned that staff do not necessarily contact families on a regular basis unless requested. LPA was also told that the family involved was notified of anything significant. At this point, LPA cannot say with certainty that the facility did or did not contact the family every time something significant happened, as stories vary. Therefore, Allegation is Unsubstantiated.
Regarding the allegation that Facility staff did not ensure that resident's room thermostat was operable.
LPA has toured the building and spoken with staff. The buidling is quite new, and the themostat was checked by maintenance, and was never broken. At this time it appears that room thermostats are accessible to change the temperature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 25-AS-20230104171718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANSEL PARK SENIOR LIVING COMMUNITY	FACILITY NUMBER: 312700574
	VISIT DATE: 07/28/2023

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

Therefore, LPA finds that the allegation is unsubstantiated.

Regarding the allegation that Resident's jewelry went missing while in care at the facility.
LPA spoke with staff and witnesses and reviewed files. LPA was not able to find any staff who had any knowledge of the jewelry in question. Therefore, LPA cannot say what might have happened. Items such as small jewelry can become easily lost, misplaced, accidentally thrown away, etc., especially in memory care as individuals may not remember what they did with an item or if someone else was involved. Therefore, allegation is unsubstantiated.

Regarding the allegation that Facility staff did not ensure proper placement and use of resident's hearing aids. LPA has spoken with staff. It appears that staff made attempts to place hearing aids in the ears of R1 each morning. Staff stated that they would only place the aids if R1 was up and out of bed. If someone came to visit early, it is possible that R1 was not out of bed yet, or staff had not had a chance to help him yet. LPA is not able to say that staff was or was not neglectful or forgetful or that they were not attempting to assist. Therefore, allegation is unsubstantiated.

Regarding the allegation that Facility staff did not keep resident's room clean of fecal matter.
LPA has spoken with staff, witnesses and toured the facility. On the date of my unannounced visit LPA found the rooms to be clean and free of odor. LPA learned that it’s possible that staff may have assisted R1 to get clean and ready in the morning, and then after breakfast he could go to his room and have an accident which he would try to take care of. It’s possible that someone could have found this situation before staff had a chance to check on him. Therefore, LPA is not able to say that staff was in any way neglectful of R1’s hygiene. Allegation is unsubstantiated.

Regarding the allegation that Facility staff did not meet resident's hygiene needs.
LPA spoke staff and learned that R1 had showers several times per week and more often when needed. As above, R1 would apparently try to take care of things himself, and may have not been clean when someone visited. Again, LPA is not able to say this was because of neglect on the part of staff. Allegation is unsubstantiated.

Regarding the allegation that Facility staff did not assist residents while eating. LPA interviewed staff and watched meals. LPA learned that staff try to encourage residents to be as independent as possible when

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 25-AS-20230104171718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANSEL PARK SENIOR LIVING COMMUNITY	FACILITY NUMBER: 312700574
	VISIT DATE: 07/28/2023

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

eating; and will assist if the resident really needed. Again, LPA is not able to say if someone really did or did not get assistance when needed. Allegation is unsubstantiated.

Regarding the allegation that Facility staff did not meet resident's laundering needs.
Through interviews with staff LPA learned that laundry is generally done once a week for each resident, and more often if needed. If clothes/bedding are wet or soiled, staff will take it out and wash it. As above, LPA learned that R1 would try to be independent and would sometimes change himself, then put wet or soiled clothes into his hamper. It is possible that this was done and staff did not immediately find the soiled laundry. However, LPA is not able to say staff was neglectful. Allegation is unsubstantiated.

Regarding the allegation that Resident was made to sleep in urine-stained bed sheets and mattress, LPA interviewed staff and learned that R1 was in the habit of making his own bed. He would apparently do this even if the sheets were wet/soiled and needed to be changed. Therefore, it is possible that visitors could have found a bed that had been “made” but still had wet sheets. LPA cannot say that staff was neglectful in this case. Allegation is unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation 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 provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3