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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002841
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:41:44 PM

Unfounded


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
07/08/2024 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240708144038
FACILITY NAME:AUBURN VALLEY SENIOR LIVINGFACILITY NUMBER:
315002841
ADMINISTRATOR:DOCMANOV, ANAMARIAFACILITY TYPE:
740
ADDRESS:3800 LORAY LANETELEPHONE:
(916) 757-7057
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:6CENSUS: 5DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jessica CampbellTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not transfer resident.
Staff do not provide adequate incontinent care.
Staff do not observe resident regularly.
INVESTIGATION FINDINGS:
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On 9/12/2024 LPA Tryon visited the facility to complete the complaint. LPA met with staff Jessica Campbell.
LPA has toured the facility, reviewed resident files, spoken with staff and Licensee. LPA was not able to speak with resident involved, as the resident has moved and current address is unknown at this time.
Regarding the allegation that staff do not transfer resident, in speaking with all staff interviewed, LPA learned that resident R1 was mostly independent and able to transfer self; sometimes needed assistance. R1 would call for staff and often 2 or 3 staff would respond to assist. R1 was taken to the table for meals, could use bathroom either independently or with assistance. LPA finds the allegation to be UNFOUNDED.
Regarding allegation that staff do not provide adequate incontinent care, as noted above, LPA learned that R1 was pretty independent or could transfer with assist. It appears staff responded quickly when called. It was learned that R1 rarely had incontinence issues and used bathroom/commode, therefore not really requiring special care. However, it appears staff did respond quickly when needed. Allegation is unfounded.
Regarding the allegation that staff do not observe resident regularly, LPA learned that staff gave a great deal of time and attention to R1, responded quickly when R1 called, and were aware of R1's needs and (continued)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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 2
Control Number 59-AS-20240708144038
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: AUBURN VALLEY SENIOR LIVING
FACILITY NUMBER: 315002841
VISIT DATE: 09/12/2024
NARRATIVE
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condition. R1 was receiving hospice services, and was regularly seen by the hospice agency staff. It appears that R1 was observed on a regular basis. Allegation is unfounded.

A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited as a result of this complaint. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2