312700574-5-9-2024-59-AS-MSEY-D58SR9-20240513140558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 04/17/2024
Date Signed: 05/09/2024 04:40:12 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
03/06/2024 and conducted by Evaluator Angela Hood

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240306093035

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:	04/17/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Deborah Taylor, Executive Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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-Residents are not receiving ADLs.
-Facility is not providing adequate food services.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/17/24, and met with the Executive Director, Deborah Taylor, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, the Department conducted interviews, obtained documentation pertinent to the investigation, and conducted an inspection of the food supply.

Allegation: Residents are not receiving ADLs.
Interviews with residents (R2 and R3) indicated that they are receiving all ADLs from care staff. R2 and R3 indicated that if they need anything staff are there and ready to assist. R2 and R3 indicated that all of their needs are being met by facility staff. Staff (S1 and S2) indicated that they have never observed other care staff not providing ADLs to residents in care.
*********************************************Continued on LIC9099-C***********************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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 5

Control Number 59-AS-20240306093035

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: 04/17/2024

NARRATIVE

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Allegation: Facility is not providing adequate food services.
Facility provided their menu for the week of 4/14/24-4/20/24. The facility provides a variety of food options for residents in care. Facility also provides an always available menu for residents, which also offers low sodium and vegetarian/vegan options upon request. LPA toured the kitchen area, and the facility has the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed kitchen staff preparing salads. LPA observed the food order invoices and the facility orders fresh produce almost daily. Facility orders all other food supplies approximately three times per week. LPA observed the sample food from the 4/16/24 lunch menu, which was all fresh food items. Interview with Culinary Director indicated that residents eat a lot of fresh fruit and vegetables in their meals. Interviews with R2 and R3 indicated that the facility provides nutritious meals to residents at the care home.

Based on observation, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
03/06/2024 and conducted by Evaluator Angela Hood

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240306093035

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:	04/17/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Deborah Taylor, Executive Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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-Due to staff negligence, resident sustained a pressure injury while in care.
-Resident sustained multiple falls resulting in fractures.
-Staff left resident on floor for an extended period of time.
-Staff did not provide a 60-day notice of rate increases.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/17/24, and met with the Executive Director, Deborah Taylor, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, the Department conducted interviews and obtained documentation pertinent to the investigation.

Allegation: Due to staff negligence, resident sustained a pressure injury while in care.
According to home health records, resident (R1) was receiving home health services from 3/28/23-12/30/23. Home health records indicated that R1 had a pressure wound that was not staged on their right index finger with an onset date of 5/9/23. The pressure wound was resolved as of 12/30/23. Home health records indicated that R1 had a stage three pressure wound located on the right ischial tuberosity.
*************************************************Continued on LIC9099-C*************************************************

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 59-AS-20240306093035

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: 04/17/2024

NARRATIVE

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The onset date was noted as 7/25/23 and resolved as of 8/11/23. On 12/18/23, the final date that R1 was seen by home health, R1 had a stage two pressure wound on their left buttock and a stage two pressure injury on their right ischial tuberosity. Both wounds were noted to be improving.

Interview with Home Health Staff indicated that R1 was receiving wound care approximately once per week. Interview also indicated that how often R1 was seen by Home Health was to the discretion of the Nurse and is based on the pressure injury status. Interview with Home Health Nurse indicated that R1 was receiving care twice per week and was receiving wound care for a pressure injury. Home Health Nurse indicated that they had no concerns regarding the care that R1 was receiving from the care home. Home Health Nurse indicated that they were not concerned with R1’s pressure wound as it was progressing and improving.

Allegation: Resident sustained multiple falls resulting in fractures.
Interview with R1’s responsible party indicated that R1 sustained a toe fracture in September of 2021. Responsible party indicated that there were other instances that R1 sustained fractures, however, was unable to provide dates of injury. According to Unusual Incident/Injury Report dated 9/13/21, R1 had pushed their pendant and was found by staff sitting on the floor of their bedroom. R1 had reported that their slipper had gotten caught under their mat and they fell. R1 returned from the hospital with a walking boot. The Department conducted a complaint investigation #25-AS-20210916083105 regarding the 9/13/21 fall incident with Unsubstantiated findings. The facility provided all Unusual Incident/Injury Reports for R1 and there was no record of any other fractures sustained. Interview with ED indicated that they are not aware of any falls that resulted in fracture besides the incident that occurred on 9/13/21. No fractures were noted in the Home Health Records between 3/8/23-12/30/23.

Allegation: Staff left resident on floor for an extended period of time.
According to the facility’s incident log, R1 sustained a fall on 11/28/23 with no injuries reported. Interview with R1’s responsible party indicated that R1 had a fall in November 2023 and R1 did not sustain any serious injuries or fractures as a result of the fall. Facility’s call button log indicated that R1 pushed their emergency call button pendant at 5:01pm. Facility’s incident report indicated that the time of the incident was 5:15pm.
**********************************************Continued on LIC9099-C************************************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20240306093035

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: 04/17/2024

NARRATIVE

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Interview with Rocklin Fire Department indicated that the 911 call was made from the facility at 5:15pm. Rocklin Fire Department report #202311280268 indicated that the alarm for service was made at 5:17pm. The report also indicated that Rocklin Fire Department arrived at the facility at 5:24pm to provide lift assistance for R1. The report indicated that R1 had no injuries and was only in need of lift assistance.

Interviews with staff (S2) indicated that they were present during the 11/28/23 incident and that 911 was contacted immediately. Interviews with staff (S1) and S2 indicated that the first priority is assessing the resident when they push their emergency call button pendant to ensure the health and safety of the resident. Interviews indicated that, following their assessment, staff would clear the pendant. Interviews with residents (R2 and R3) indicated that staff respond to their emergency call buttons immediately. According to the facility’s Procedures for Resident in the case of an accident or emergency, if a resident has fallen, do not immediately move him/her. Also, if a resident appears to have no serious injuries and the resident is too heavy for two care associates to lift together call 911. Interviews with ED, S1, and S2 indicated that on 11/28/23, staff were unable to lift R1 and required assistance from emergency services.

Allegation: Staff did not provide a 60-day notice of rate increases.
Interview with ED indicated that R1 had a rent increase while residing at the care home. The facility issued a 60-day notice for rent increase to R1 on 11/1/22. The 60-day notice indicated that rent would increase by $343 effective 1/1/23 and that the enclosed Residency Agreement Addendum Form must be returned to the community Business Office by 12/15/22. The Residency Agreement Addendum regarding rent increase was signed by R1 on 12/15/22. According to R1’s Emergency Information Sheet, R1 is their own responsible party and have a medical Power of Attorney. Facility invoices dated 12/1/22-4/30/23 indicated that the rent increase for R1 became effective 1/1/23.

Based on interviews conducted and documentation reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

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