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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:38:37 PM


Document Has Been Signed on 05/09/2024 04:38 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:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Deborah Taylor, Executive DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced today, 5/9/24, to conduct a case management visit regarding information obtained during a complaint investigation #59-AS-20240306093035 that was completed on 4/17/24.

Resident (R1) was receiving home health services from 3/28/23-12/30/23. According to home health records, R1 had a stage three pressure wound located on the right ischial tuberosity with an onset date of 7/25/23. Interviews with Home Health staff indicated that R1 was receiving wound care approximately once or twice per week. The facility did not request an exception from the Department for the prohibited health condition and R1 was not receiving hospice care while residing at the care home.

Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 809-D page.

Exit interview was conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/09/2024 04:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.

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Faciltiy agrees to submit a statement of understanding. Facility will conduct an in-service training with care staff regarding the importance of communication with home health nurses. Facility will submit to LPA information regarding in-service, including time and date of in-service and training material, by POC due date of 5/10/24.
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This requirement is not met as evidenced by:
Based on records reviewed and interviews conducted, the facility did not request or obtain an exception for resident, R1's, stage 3 pressure wound, which posed an immeidate health, safety, and personal rights risk to residents in care.
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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) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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