312700739-4-12-2024-59-AS-MSEY-D4UQNF-20240501121902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:51:59 PM

Substantiated

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

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: 123	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Henry Cole, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow its visitor policy.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence a complaint investigation. Also present to conduct a joint investigation was an Ombudsman. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection.

During today's inspection, LPA and Ombudsman discussed the allegations with the Administrator, (2) staff, resident (R1) and a family member of R1's conservator. LPA also reviewed video camera footage and the visitor sign-in log for Monday, April 8, 2024, and discussed the facility's visitor's policy as stated in the Resident Handbook.

The findings are as follows for the (1) above allegation: Facility did not follow its visitor policy.

The other (2) allegations need additional investigation before a finding can be delivered.
cont on 9099C-1...

Substantiated

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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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 4

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: 04/12/2024

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

*9099C-1 LPA viewed video coverage from Monday, 4/8/24, at approximately 1:12 pm where (2) individuals walked into the main lobby and over to the reception area. LPA reviewed the visitor sign-in log for the same day and observed that only the female guest had signed in.

Interview with receptionist who was working at the time these (2) guests arrived stated she didn't recognize the individuals or name of the person who signed in and the male individual was not requested to sign the visitor log as required. The same staff stated that there are some visitors who do not sign-in as required and they are trained that all visitors need to sign-in for the fire marshall.

Review of the visitor log for the same day confirms that the female visitor did not sign-out when leaving the building at approximately 2:28 pm, per video surveillance footage viewed. The visitor log for the same day also shows (16) other visitors who signed in and (5) who did not sign out.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview. Copy of report and appeal rights 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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/26/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreements. (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to post a sign at the front reception/entry area requesting all visitors sign-in and sign-out when entering/leaving the facility. Photo of the sign to be posted will be emailed to the Department by 4/26/24. Training to be conducted by front desk staff on the visitor policy. Also due by 4/26/24.
	8 9 10 11 12 13 14	Based on video footage, visitor log and interviews conducted, the Licensee did not ensure that the male visitor signed in on 4/8/24 at approximately 1:12 pm, and the female visitor signed out, at approximately 2:28 pm per video footage, which posed a potential health and safety risk to residents in care. The visitor log for 4/8/24 shows (16) other visitors who signed in and (5) who did not sign out.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4