312700739-10-4-2023-59-AS-KHOS-CWPRQZ-20231017131421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:05:08 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
08/04/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20230804135453

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: 124	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Henry Cole, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff does not ensure resident's nail care needs are being met.
Staff does not allow resident access to personal items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Henry Cole during today's facility visit.
LPA investigated allegation of “Staff does not ensure resident's nail care needs are being met.” LPA interviewed facility staff, responsible parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R1’s fingernails and toenails were not being managed and were very long. Relevant party sent photographs, and LPA observed R1’s fingernails appearing to be overgrown and long. LPA interviewed administrator in which he stated R1 receives visits from a podiatrist every quarter. LPA observed podiatrist documentation in which it states R1 was seen on 11/22/21,4/05/22, 6/20/22, 8/17/22, 10/28/22, 01/17/23, 4/19/23.
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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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 59-AS-20230804135453

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: 10/04/2023

NARRATIVE

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Podiatry documentation states R1’s nails were long, and they were trimmed. LPA spoke to R1’s responsible party in which they stated R1 denies care, and at times it’s hard to get resident to accept nail care. The responsible party stated that on August 12^th, the responsible party was able to get R1 to a salon and receive a pedicure and manicure. The responsible party states they are happy with the care that is being provided to R1. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, "Staff does not allow resident access to personal items." LPA interviewed facility staff, responsible parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated the facility is restricting R1's access to her personal belongings which include clothing and toiletries. LPA interviewed the memory care manager in which she stated R1 has a behavior of throwing away personal items. Due to memory impairment, R1 continues to throw away clothing and other items she does not recognize as her own. Facility locks R1’s clothing and toiletries in a closet, and each day (and as needed), a caregiver will unlock and provide R1 with a change of clothes and grooming items. This has prevented R1 from losing personal items. LPA reviewed facility documentation in which it states on 6/09/23 facility staff observed resident outside window screen to be off and R1’s clothes and personal belongings thrown outside. On 6/10/23 staff observed R1’s bedroom window frame off and R1’s clothing was observed to be thrown out the window. On 6/13/23 staff observed R1 bringing out her clothing from her room. On 6/15/23 staff observed R1 had thrown her clothing out the window. LPA reviewed facility care plan in which it states R1 has a history of aggression toward staff, refuses care, and has behaviors of throwing her and her husband’s clothing and grooming items away. LPA interviewed R1’s responsible party in which they stated R1 has thrown many items away and it was getting expensive to replace. The Responsible Party stated they agreed with the facility to have clothing and personal items locked up unless there was staff present. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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