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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:32:43 PM

Document Has Been Signed on 06/11/2024 04:32 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/
DIRECTOR:
HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 142CENSUS: 127DATE:
06/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Henry Cole, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain additional information for (2) incident reports recently submitted to the Department. LPA met with Henry Cole, Administrator and stated the reason for the inspection. The following residents and incidents were discussed:

On 5/14/24, resident (R1), who was independent with her medications, stated she didn't want to live anymore and was going to take the vitamins stored in her room. Staff immediately removed the vitamins and contacted the Police, resident's family and hospice staff. The police arrived to interview (R1) and a 1:1 caregiver was assigned until a hospice nurse and social worker were able to interview resident. The Administrator stated (R1) was falling a lot and is now stabilized.

On 6/3/24, resident (R2) lost her balance and fell while walking in the hallways, around 3:15 pm. Resident injured her right elbow and forehead, causing bleeding, and was sent to the emergency room. Resident was admitted and returned to the community later on 6/3/24 (9:40 pm). No follow up appointments were scheduled or any new medications prescribed. (R2) is back in the community and is doing fine.

The facility responded immediately and appropriately to each resident and submitted incident reports (LIC624) to the Department timely.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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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