312700739-4-26-2024-59-AS-MSEY-D4UQNE-20240501121902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 04/26/2024
Date Signed: 04/26/2024 05:13:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240409113054

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: 120	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Henry Cole, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff allowed conserved resident to sign unauthorized forms.
Staff are not properly trained.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 4/9/24. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection.

During the course of the investigation, LPA interviewed the Administrator, Memory Care Director, (5) staff, resident (R1) and (2) family members of (R1's) conservator. LPA reviewed documentation related to (R1's) conservatorship and viewed facility video footage from 4/6/24. The results of the investigation are as follows:

Allegation: Staff allowed conserved resident to sign unauthorized forms. The allegation states that resident (R1's) family member visited on 4/6/24, along with an unidentified male, and asked (R1) to sign some documents without the conservator's consent.

Cont on 9099C-1...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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 3

Control Number 59-AS-20240409113054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 04/26/2024

NARRATIVE

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9099C-1... Resident has a diagnosis of Dementia and is also conserved. LPA was provided with court documents from both the Administrator and (R1's) family member showing that (R1's) family member was appointed conservator over (R1's) person and estate on 1/13/22. Resident resides in the memory care unit of the facility. The Administrator, Memory Care Director and family member indicated that there are no restrictions in place for not allowing the female visitor to visit with (R1).

LPA conducted an interview with (3) staff who were present on 4/6/24 when (R1) was visited by another family member, who is not the conservator, and an unidentified male. All interviews indicated that resident's family member and the male visitor entered the Memory Care Unit at 1:15 pm and asked to speak to (R1), who was not in her room then. One staff walked with the visitors to locate (R1) who was in a nearby area and then walked (R1) and the visitors back to (R1's) room. While walking back to (R1's) room, staff overheard the female visitor say she "had some papers for (R1) to sign", and immediately reported this information to the lead staff who told the Administrator and the Memory Care Director. Lead staff and the Memory Care Director confirmed this information.

The Memory Care Director stated she responded to the information received and walked into (R1's) room, two separate times, during the visit and asked if the visitors needed anything and was told by the female visitor they were "just visiting". The Director confirmed she saw the male visitor holding a clipboard and he continued to wear a hat and sunglasses during the entire visit. The Director stated the she asked (R1) if she would like to visit with the visitors, and (R1) stated she did but was only able to identify the female visitor.

The video footage and interviews conducted show the male visitor was carrying an envelope or clipboard with papers when entering the facility and continued to wear sunglasses and a hat until he left the community, an hour later. The male visitor identified himself as a "family friend" and only provided a first name.

Staff interviews confirmed that staff are aware of (R1's) specific family member that holds Power of Attorney (POA) but not all staff were clear that (R1) is conserved, or if any other residents are. Staff did indicate they are aware that residents with a diagnosis of Dementia or are conserved, should not be signing any legal documents without approval from their responsible person or conservator.

cont on 9099C-1...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240409113054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 04/26/2024

NARRATIVE

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9099C-2... Based on information obtained during the investigation, it appears the facility acted promptly in notifying other staff, (R1's) family member(s) and conservator, and also checking on (R1's) safety twice during the visit. There is currently not a restraining order in place against either visitor.

LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff are not properly trained. The allegation states staff need to be aware that the resident is under conservatorship and resident should not be allowed to sign any documents from anyone without the conservator's approval.

Staff interviews confirmed that staff are aware of (R1's) specific family member that holds Power of Attorney (POA) but not all staff were clear that (R1) is conserved, or if any other residents are, or what the differences are. Staff did indicate they are aware that residents with a diagnosis of Dementia or are conserved, should not be signing any legal documents without approval from their responsible person or conservator.

The Memory Care Director stated that staff are trained on visitation and most family members will call and give staff an alert if a resident will have a visitor to the community. The Director stated "we usually recognize the visitors" and if staff doesn't recognize the visitors, they will ask the resident if they would like to have that visitor and the resident will usually indicate he/she would. One staff stated the female visitor visits once in a while and has never been observed to be carrying paperwork with her to visit (R1).

A citation was issued on 4/12/24 for the facility not following its visitor policy in requiring all visitors to sign in and out during each visit.

LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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