312700574-10-26-2021-25-AS-LMUZ-C8CTHZ-20211101144534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 08/27/2021
Date Signed: 10/26/2021 08:29:22 AM

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
07/08/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210708083425

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: 44	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	07:41 AM
MET WITH:	Benjinim Martin, Sales Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not attend to resident's hygiene care needs in a timely manner
Residents do not received meals in a timely manner
Residents are not assisted with their medication in a timely manner

INVESTIGATION FINDINGS:

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Amended to change Confidential to Public
On August 27, 2021, Licensing Program Analyst, (LPA) DeAnna Williams-Lyons arrived at the facility and met with to deliver complaint investigation. Martin Sales Director Benijmin Martin on findings. Community Care Licensing (CCL) received a complaint allegation stating residents do not received meals in a timely manner, Staff do not attend to resident's hygiene care needs in a timely manner and residents aren't assisted with their medication in a timely manner. During the course of this investigation, LPA conducted interviews with staff and residents, reviewed facility records, staff and resident’s records, staff schedules, incident reports, medication logs, and charting notes.

Allegation: Residents do not received meals in a timely manner
LPA interviewed 5 staff and 4 residents. It was alleged that residents do not receive meals in a timely manner. 5 staff members that were interviewed confirmed that there were some incidents of residents receiving their meals a bit late since Covid-19.

To continue see 9099-C...

Unsubstantiated

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: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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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