312700574-10-21-2021-25-AS-LMUZ-C87TPK-20211027145429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:20:01 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
10/06/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211006142103

FACILITY NAME:	ANSEL PARK SENIOR LIVING COMMUNITY		FACILITY NUMBER:	312700574
ADMINISTRATOR:	BERKELEY, LORI		FACILITY TYPE:	740
ADDRESS:	1200 ORCHID DRIVE		TELEPHONE:	(916) 250-0770
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	100	CENSUS: 47	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	10:51 AM
MET WITH:	Lori Berkeley, Executive Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff are not following physicans orders
Resident did not get blood surage checks in a timely manner

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 continue investigating Complaint #
25-AS-20211006142103. 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.

LPA and LPM reviewed documentation for R1 and observed physican orders with orders for R1 to have blood sugar checked four (4) times a day, 7:30am, 11:30am, 5:00pm and 9:00pm. Additionally, orders indicated special instructions that R1 have blood sugar checked before meals and at bedtime.

To continue see 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (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)

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Control Number 25-AS-20211006142103

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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During interview with Administrator, it was learned that R1 does not have his meals at the same time everyday so following the time frame has been a challenge. LPA and LPM reviewed blood sugar logs and observed although the facility is not having R1's blood sugar checked at indicated times, blood sugar logs indicate R1's blood sugar is taken four (4) times a day relatively close to indicated times.

Based on records reviewed and interviews conducted, the facility is following R1's physician's orders and therefore R1 is getting blood sugar checks in a timely manner. The above allegations are UNFOUNDED, which meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and a copy of this report was given to Lori Berkeley.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (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)

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