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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:01:16 PM


Document Has Been Signed on 09/12/2023 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:DEBORAH TAYLORFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rebecca Reaves, RSDTIME COMPLETED:
01:30 PM
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On 9/12/2023 LPA Tryon visited the facility to look into an incident involving a resident fall/hospitalization.
LPA spoke with Resident Services Director Rebecca Reaves. LPA interviewed Ms. Reaves regarding the incident and history and situation; and requested copies of several resident records related to the resident and incident.

At this time, it appears staff responded to the fall immediately, assessed the resident and situation, notified responsible parties, and followed up on the situation to the best of their ability given the information available at the time, respecting the resident's and family's wishes and decisions; and when it was found that further follow-up was necessary, staff immediately followed up appropriately. Responsible parties were made aware of the situation and involved in decisions.

LPA will review documents provided and consult with CCL managers to determine if anything further is needed or any further action warranted at this time.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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