312700574-3-2-2022-25-AS-LMUZ-CCAPZY-20220307104616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 02/17/2022
Date Signed: 03/02/2022 12:54:12 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
11/10/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211110130832

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:	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Deborah Taylor, Execitive Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident did not get blood sugar checks in a timely manner

INVESTIGATION FINDINGS:

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***Report was amended to make Public not Confidential***
On February 17, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for Complaint # 25-AS- 20211110130832. LPA met with Deborah Taylor, Executive Director and explained the purpose of the visit.

Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of g 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 the following Personal Protective Equipment (PPE) was worn: N-95mask. Additionally, LPA was screened by the front desk personnel upon arrival.

To continue see 809-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: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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-20211110130832

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: 02/17/2022

NARRATIVE

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Community Care Licensing received a complaint allegation stating Resident did not get blood sugar checks in a timely manner. During the investigation, LPA reviewed R1’s medical file and the blood sugar log of check times and administration of insulin. Physician’s orders states 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.

Interviews with staff reveals, R1’s daughter orders diabetic plates which consist of mostly vegetables and according to staff, most of the time, R1 would refuse to eat. R1 doesn't like to be told what to do or what to eat. R1 would refuse all food when R1 feels his blood sugar it too high. S2 said, "Sometimes he would yell at me when he gets upset. He doesn't like his diabetic plate and won't eat it. R1's daughter thinks the staff are not complying to his doctor's orders, but it is him not the staff. Staff here at the facility try to help him out as much as possible but he makes it very hard to do. He won't follow his own doctor's orders and we can't force him."

It was learned that R1 does not have his meals at the same time every day. LPA reviewed blood sugar logs and observed although the facility is not having R1's blood sugar checked at indicated times, blood sugar logs indicates 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 allegation is UNFOUNDED, which meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Per California Code of Regulations, Title 22, No citations were issued.
An exit interview was conducted, and a copy of this report was given to Deborah Taylor.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

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