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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:58:31 PM


Document Has Been Signed on 04/09/2024 04:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 123DATE:
04/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Henry Cole, Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator, and stated the reason for the inspection. LPA and Administrator discussed the following:

Resident (R1) was sent to the ER on 4/2/24 when care staff were not able to remove the contact from resident's right eye. The contact was removed and resident returned the same day with Polymyxin B – 1 drops to be administered in the affected eye 3 times a day for 7 days. A new eye contact ordered. Facility staff has tried to encourage him to use his glasses but he prefers contacts. This is an isolated incident.

Resident (R2) was found to be intoxicated, in his room, on 4/4/24 and sent to the emergency room. Resident has since transferred to a skilled nursing facility for physical therapy and is expected to return in (2) weeks. Administrator stated he has discussed the situation with resident's family members previously and in recent weeks and will discuss obtaining an order from the doctor for a limited daily amount of alcohol. The Administrator stated (R2) is alert and oriented and independent with purchasing alcohol. LPA reviewed resident's physician's report (7/28/23) where it's noted resident consumes alcohol and has a related medical condition. Resident was sent to the ER in February 2024 for a similar incident.

Administrator will reach out again to resident's family member(s) to schedule a meeting to discuss obtaining an order for a daily alcohol limit and keep the Department updated.

Also discussed was how the incident report should be completed as best possible and submitted to the Department within (7) days of the incident.

There are no citations issued in today's report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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