312700739-3-2-2022-25-AS-LMUZ-CC6TT5-20220303140009

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 02/16/2022
Date Signed: 03/02/2022 12:41:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220125161717

FACILITY NAME:	PINES, THE		FACILITY NUMBER:	312700739
ADMINISTRATOR:	ROBERTSON, JOHN		FACILITY TYPE:	740
ADDRESS:	500 W RANCHVIEW DRIVE		TELEPHONE:	(916) 672-5019
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	142	CENSUS:	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	John Robertson, General Manager		TIME COMPLETED:	09:44 AM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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***Amended to make Public***
On February 16, 2022, at 8:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings. LPA met with the General Manager John Robertson and informed him the reason for the visit.

Prior to visit, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and worn a mask for Personal Protective Additionally, LPA was screened by front desk personnel upon arrival.
This agency has investigated the complaint alleging an illegal eviction. LPA reviewed records during this investigation and conducted interviews. LPA observe a new assessment for R1, pre-admission assessment, and R1’s LIC602. Through record review, LPA observed R1 care needs increased from time of admission to current assessment.
To continue see 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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 25-AS-20220125161717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 02/16/2022

NARRATIVE

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On 1/17/22, the facility sent R1 to the hospital due to R1 not getting out of bed. The General Manager contacted R1’s family and met to discuss and advise R1’s family, the
facility is unable to take R1 back to the facility due to a change of condition and because he is a safety concern. R1 is a fall risk and is a walker with dementia. The nurse did an assessment and it was determined that R1 was no longer a good fit for the facility. The facility doesn’t have the staff to watch him 24 hours a day, and they do not have the staff to ensure he will not fall, and the family needed to find another placement for R1. A rehabilitation facility was suggested because the resident might be able to access more services to recover better. General Manager stated the facility never provided R1 and/or R1's family a written eviction notice; it was an informational conversation with the family to let them know what their options were going forward. Responsible party moved R1 out of the facility from the hospital. Currently, R1 is at the new placement. It appears there was a communication issue between the responsible party and the General Manager.

Based on LPA’s review of records, interviews conducted, and R1 was never given an eviction notice letter or was abandoned at the hospital, the department has determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to John.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

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