312700574-3-3-2022-25-AS-LMUZ-CCAQ39-20220307104821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 02/23/2022
Date Signed: 03/03/2022 05:11:39 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
09/16/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210916083105

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:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Deborah Taylor, Executive Director		TIME COMPLETED:	11:37 AM

ALLEGATION(S):

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Multiple residents sustained injuries while in care
Staff do not attend to resident pendant calls in a timely manner

INVESTIGATION FINDINGS:

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****Amended to make Public***
On February 23, 2022, at 10:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver finding for complaint # 25-AS- 2021916083105. LPA met with Deborah Taylor and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a risk assessment. LPA ensured she applied hand sanitizer before entering the facility and
worn a mask for the Personal Protective Equipment (PPE).

On 9/16/21, The Sacramento Adult and Senior Care Regional Office (RO) received a complaint report regarding allegations that multiple residents fell and sustained serious injuries due to lack of care and supervision. The RO referred this case to the Investigation Branch to conduct the full investigation in reference to the allegations.

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: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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-20210916083105

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: 02/23/2022

NARRATIVE

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On 9/13/21, Resident #1 (R1) fell in R1’s private apartment at the facility and sustained three broken toes. R1 was interviewed and stated R1 is independent and able to ambulate without assistance from staff. R1 tripped on a mat in the sewing room and was unable to get up. R1 pressed pendant and staff responded. Call log shows pendant was pressed at 12:30pm and acknowledged in 12 minutes. R1 was not a fall risk with no history of falls.
On 9/14/21, Resident #2 (R2) fell in the community restroom at the facility and sustained a fracture vertebra. R2 said, R2 fell after using the restroom when going to the sink to wash hands. R2 pressed pendant for help. Call log shows pendant was pressed and acknowledged in 12 minutes. R2 was not a fall risk and was able to ambulate at the time of the fall.
On 9/13/21, Resident #3 (R3) fell in R3’s private apartment at the facility and sustained a fracture to the humeral head. R3 was interviewed and could not recall details of what happened. Call log shows R3 pressed pendant at 8:16 and staff responded in 11 minutes. R3 previously fell in June 2021 and had not had any falls since. R3 was able to be left unsupervised in her room. R3 medical records indicate R3 was able to ambulate with a walker.
This department has investigated the complaint. Based on records reviewed and interviews conducted with residents and staff, the allegations that multiple residents fell and sustained serious injuries due to lack of supervision and staff do not attend to resident’s pendant calls in a timely manner, is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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