312700739-9-8-2022-25-AS-KHOS-CK4MVU-20221011095720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:21:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
09/01/2022 and conducted by Evaluator Cassie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220901132401

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: 129	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Henry Cole, General Manager		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility is refusing resident visitation and calls.
Facility not assisting with resident glasses and hearing aid daily.

INVESTIGATION FINDINGS:

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On 9/8/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct an investigation and deliver the findings for the allegations cited above. LPA met with General Manager, Henry Cole (S2), and explained the purpose of the visit. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, confirmed there are currently no positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During today's inspection, LPA interviewed (3) staff, (1) visitor, (1) resident and obtained copies of resident's (R1) Admission Agreement, Preplacement Appraisal, LIC 602, CA Durable Power of Attorney, Care Plan/Activities Daily Living and R1's shower schedule.

Please continue on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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-20220901132401

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
	VISIT DATE: 09/08/2022

NARRATIVE

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Continued from LIC 9099...

Based on observation and interviews, LPA observed S1 informing a visitor (SC) to contact R1's Power of Attorney (POA) prior to visitation, S2 informed LPA that POA requested facility to notify him of all R1's visitors. S1 informed LPA it was part of protocol for visitors of R1 to contact POA until today when S2 informed S1 it was no longer a protocol. SC informed LPA that during her previous attempted visitations and calls, SC was informed she would need to inform POA first. SC informed LPA R1 was admitted to the facility with a hearing aid. S3 reported to LPA R1 only has glasses at the facility which is kept in the Med Room or in R1's room since R1 often leaves it around the facility. S3 informed LPA caregivers remove residents hearing aids at night to charge in the Med Room, and signs the document with their initial. S3 reported to LPA R1 does not have a hearing aid. LPA observed POA informing S2 on speaker phone that R1 did have a hearing aid and it may have been misplaced over the years. LPA observed R1's Care Plan/ADL "Action: Hearing Level of Assistance- Moderate" to be initialed on Care Day Shift 1 Thursday 1st to Thursday 8th, and Care Evening Shift 1 Thursday 1st to Wednesday 7th.

As a result of the investigation, LPA finds the allegations to be (S) SUBSTANTIATED - A finding that the
complaint is Substantiated means that the allegation is valid because the preponderance of the evidence
standard has been met.

California Code of Regulations, Title 22, are being cited.
Please see the attached LIC 9099-D for deficiencies.

Exit interview conducted with General Manager, a copy of the report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220901132401

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PINES, THE	FACILITY NUMBER: 312700739
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/23/2022 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator is to conduct a training of PIN 22-07 and PIN 21-48 with department managers and receptionists discuss POA's and visitation rights in general for residents. Documentation of agenda/attendees with statement of compliance is to be provided to CCLD Regional Office by Friday 9/23/22 via email or fax.
	8 9 10 11 12 13 14	Based on observation and interviews, Licensee did not ensure R1 was able to visit with visitors without prior notice which posed an potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/23/2022 Section Cited CCR 87465(a)(3)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed by each facility. The plan shall encourage routine medical...care and provide for assistance in obtaining such care, by compliance with the following: (3) When residents require... hearing aids, the staff... shall assist such persons with their utilization as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee is to contact R1's primary care physician to notify a need for hearing aid replacement. Licensee, R1 and POA is to find resolution for R1's glasses misplacement issue: such as installing glasses straps.
	8 9 10 11 12 13 14	Based on observation, interviews and record review, staff failed to assist hearing aid to R1 as prescribed. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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