312700574-5-19-2022-25-AS-LMUZ-CF7298-20220607171131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 02/23/2022
Date Signed: 05/19/2022 09:42:42 AM

Unsubstantiated

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
10/25/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211025134135

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: 56	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Deborah Taylor, Executive Director		TIME COMPLETED:	10:33 AM

ALLEGATION(S):

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Facility staff did not incidents as required.
Facility staff delayed timely medical care for a change of condition.

INVESTIGATION FINDINGS:

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On February 23, 2022 , Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #25-AS-20211025134145.LPA met with Deborah Taylor , Executive Director and explained the purpose of the visit.
Prior to initiating the visit, LPA complated the required COVID-19 testing Protocols, and a daily self screening questionaire for symptoms of COVID-19, and completed a facility risk assessment. LPA ensured
she applied hand sanitizer before entering the facility and a N-95 mask was worn. Additionally, LPA was acreened by the front desk personnel upon arrival.
LPA reviewed facility documents on the days in question. Regarding the allegation stating Facility staff delayed timely medical care for a change of condition; the data of occurrences was actually 3/3/21, order was requested from primary care physician on 3/3/21, 3/4/21, and 3/5/21, physician's office not open on Saturday the 6th and sunday the 7th, and facility received the on Monday 3/8/21.

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: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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-20211025134135

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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The specimen was obtained, returned to Kaiser Hospital, and results received on 3/8/21 with negative result. An LIC624 (serious incident report) was completed and faxed to licensing on 3/8/21. The physician's office did not respond to facility's request in a timely manner. Although the urinalysis was not completed until 3/9/21, result was negative for a UTI. The delay in testing did not risk R1's health. The allegation stating staff did not report incident as required was investigated and ruled on September 10, 2021, with a substantial findings. A citation was issued on the same day.

Fall on 11/27 2020
According to interviews R1 was apparently running in the community and fell with no injuries. Primary Care physician and POA were notified. No state report was required. Resident was encouraged to walk and not run to move about, there were no falls in the community prior to this one.

Based on records reviewed and interviews conducted by LPA, the allegations were UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evident to prove that the alleged violation occurred.

Medication Error 12/16 2020
Facility has electronic MARs, (Medication Administration Report). There was no deviation or sign that there was a medication error with vitamin D, on the date given or the month of December 2020 that was pulled up. In addition, the primary care physician discontinued this medication completely on 12/18 2020.

Foot closed on Resident #1 by Resident #2 in December 2020.
There is absolutely no documentation (external or internal) that this even even occurred.

Based on the above, there is insufficient information available to determine if the incident occurred.
The allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evident 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: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC9099 (FAS) - (06/04)

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