312700739-7-10-2023-59-AS-KHOS-CU4KDA-20230726074826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 07/10/2023
Date Signed: 07/10/2023 12:50:38 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20230706103301

FACILITY NAME:	PINES, THE		FACILITY NUMBER:	312700739
ADMINISTRATOR:	HENRY COLE		FACILITY TYPE:	740
ADDRESS:	500 W RANCHVIEW DRIVE		TELEPHONE:	(916) 672-5019
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	142	CENSUS: 127	DATE:	07/10/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Henry Cole, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility dishwasher is in disrepair
Staff are not properly cleaning

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Henry Cole during today's visit.

LPA investigated allegation, "Facility dishwasher is in despair" and "Staff are not properly cleaning". LPA interviewed staff and completed a facility tour. Administrator stated the dishwasher in the kitchen is broken but they have leased a dishwasher through an outside vendor and are waiting for the dishwasher to be delivered. Staff have been serving residents with disposable silverware and plates until the new dishwasher is delivered and installed. The kitchen staff have been manually washing pots and pans per the kitchen instructions.
Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 59-AS-20230706103301

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 07/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA toured the kitchen and found the kitchen to be clean and sanitary. All dishes had been cleaned and LPA observed the manual washing procedures posted above the sink area. LPA obtained documents which indicated dishwasher has been ordered and is pending delivery.

LPA toured the facility with administrator which included the dining room, and common living areas. LPA observed all areas to be clean, sanitary, and free from odor. Administrator stated there is housekeeping staff present in the facility 7 days a week from approximately 8 AM to 5 PM. Housekeeping cleans resident rooms one time weekly and as needed. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2