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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920040
Report Date: 04/09/2025
Date Signed: 04/09/2025 02:52:30 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
09/26/2024 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20240926141557
FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:JENNIFER FUSTONFACILITY TYPE:
740
ADDRESS:3625 BLUE OAKS DRTELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: 43DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alexis Thacker, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident developed Stage 4 pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Todd Tryon visited the facility unannounced on 04/9/25 to deliver the findings of the investigation completed by the Department. LPA met with Executive Director Alexis Thacker.
During the course of the investigation, CCL staff has interviewed witnesses, staff, residents, outside agencies, reviewed documentation, reviewed medical records.
Neglect: Lack of care/ supervision resulted in resident R1 developing stage four pressure injury.
Based on interviews, medical documentation, and facility records, it was determined that the
facility failed to provide adequate care and supervision to Resident 1 (R1), resulting in the
progression of a pressure injury from stage two to stage four within a span of seven days. The
facility did not ensure proper wound care, consistent repositioning, or timely medical attention, which contributed to R1's decline and subsequent admission to hospice care.
Based on review of the medical documentation, on 6/19/2024 R1's medical records documented a stage two pressure ulcer on the right buttock and a deep tissue injury on the left lower back. On 6/26/2024 during the initial home health visit, R1's condition had significantly worsened, and the pressure injury had

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 5
Control Number 59-AS-20240926141557
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 315920040
VISIT DATE: 04/09/2025
NARRATIVE
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progressed to stage four, requiring hospice intervention. Hospice records indicated severe tissue breakdown, with a portion of the wound being unstageable due to necrosis and surrounding non- blanching purple skin, further confirming a lack of adequate care.
Based on staff interviews S1 stated that R1 did not have pressure sores upon admission but
developed one approximately a month before discharge. S1 observed that wound dressing changes were
not done frequently enough, and staff were not consistently repositioning R1 every two hours as
required. S1 and S2 reported that caregivers were not responsible for wound care, and wound
dressing changes were supposed to be conducted by Med Techs or home health nurses. However,
dressing changes were observed to be inadequate, with S2 specifically noting that the dressing was
sometimes soaking wet, indicating prolonged exposure to moisture and lack of timely intervention.
S2 and S3 confirmed that R1 was not always repositioned every two hours, with gaps of up to five
hours between changes. S2 further corroborated that the pressure sore worsened significantly within
a week, indicating an accelerated deterioration due to lack of preventive care. According to S4 and
S2 the facility had protocols for room checks every two hours and documentation of skin integrity
issues.
However, no facility records were provided to demonstrate consistent adherence to these protocols
for R1. Staff interviews revealed staff shortages, with only one or two caregivers present at times, which impacted R1's care. Despite S2 stating that staff were advised to reposition R1 every two hours and place pillows to offload pressure, interviews with multiple staff members revealed inconsistent compliance, leading
to the worsening of the wound.

Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.


SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/26/2024 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20240926141557

FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:JENNIFER FUSTONFACILITY TYPE:
740
ADDRESS:3625 BLUE OAKS DRTELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure social interactions and activities were provided to resident.
Staff did not ensure resident's personal hygiene needs were being met.
INVESTIGATION FINDINGS:
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CCL staff has spoken with facility staff and former staff, witnesses and residents. CCL learned that resident R1 was mobile at move -in to the facility and was able to come out and join activities with others. LPA learned that within a short time after moving in to Sierra Ridge, R1 began to lose mobility, body became more stiff/rigid, and appeared to be in pain a lot of the time whenever moved or staff attempted to move R1, who would have a "pained look". R1 began to be in bed more because of the apparent pain it caused to get up and out of bed. Staff related that they would attempt to get R1 up to go to meals in the dining room or engage in activities, but R1's body would be rigid, and R1 would appear to be in a great deal of pain. When staff did get R1 into a wheelchair, staff would need to hold R1 up in the chair while pushing around, or R1 would slump over, and often fell asleep when staff did take R1 to activities. LPA learned that staff would attempt to sit with R1 while eating for company. At this point, it is not possible to say that staff failed to try to engage R1 in social interactions, as by staff accounts attempts were made, but movement appeared to cause R1 so much pain that R1 was most comfortable in bed. Therefore, allegation is found to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240926141557
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 315920040
VISIT DATE: 04/09/2025
NARRATIVE
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Regarding Hygiene needs being met, again, staff related that R1 was very stiff/rigid physically, and movement appeared to cause pain/distress. Staff stated that a nurse from outside agency (wound care/hospice) was working with R1 and was reportedly
bathing/cleaning R1 several times a week; but it's not clear if it was adequate. Staff related that they would clean R1 also. It appears that facility staff attempted to keep R1's hygiene needs met, but due to stiffness, pain, and wounds, it was difficult to move R1 around to provide hygiene. At this point it is not possible to say whether better care could have been provided given all the circumstances; or whether there was actually any neglect on the part of staff. Allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20240926141557
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 315920040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains
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The facility must submit a Plan of Correction (POC) within 24 hours, detailing the following: Preventative Measures -A detailed plan on how the facility will prevent similar incidents, including staff training, monitoring systems, and wound care protocols.
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or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record review, R1 had a stage four pressure injury and did not report worsening of pressure injury to home health which poses an immediate health and safety risk to residents in care.
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An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5