312700739-9-8-2022-25-AS-KHOS-CK4LY8-20221011090954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:23:14 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
09/02/2022 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20220902100128

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: 126	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 restricting visits.

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 finding for the allegation 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 (2) staff, (1) visitor, (1) resident and obtained copies of resident's (R1) Admission Agreement, Preplacement Appraisal, LIC 602, and CA Durable Power of Attorney.

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-20220902100128

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.

As a result of the investigation, LPA finds the allegation 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.

Although, allegation was found to be substantiated, California Code of Regulations, Title 22, will not be cited as facility has been cited CCR 87468.1(a)(11) on 9/8/2022 for similar allegation in a different complaint, Control Number 25-AS-20220901132401.

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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