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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920040
Report Date: 10/22/2025
Date Signed: 10/22/2025 02:29:58 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
07/17/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250717092158
FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:ALEXIS THACKERFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRIVETELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: 47DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tony SellersTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility did not allow resident to go their doctor appointment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Kerry Hiratsuka conducted this unannounced complaint visit to deliver the results of the allegation above.

LPA interviewed Administrator and staff. LPA reviewed records. One day, R1’s power of attorney (POA) arrived at the facility to take R1 to an appointment. Interviews indicate staff were instructed to call the R1’s POA for instructions before the resident was allowed to leave the facility. After the doctor's visit R1’s POA changed and the documentation was provided to the facility. Facility staff contacted the incorrect POA resulting in R1 missing their appointment. R1’s POA left the facility because they were too late to make the appointment. Although the facility did not restrict the resident from attending their appointment, the facility caused an unnecessary delay resulting in the resident missing their appointment.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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-20250717092158
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: 10/22/2025
NARRATIVE
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Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.


The following deficiencies were cited on 9099-D, per Title 22 Regulations. Immediate civil penalties of $250.00 were issued because this is a repeat violation within the past 12 months and shall accrue at $100.00 per day until corrected. Appeal rights were left with facility representative.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250717092158
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: 10/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2025
Section Cited
CCR
87468.1(a)(6)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
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By October 23, 2025, the licensee shall come up with a written plan of correction on how they shall ensure staff understand the limitations of what a power of attorney may and may not do and what type of training they shall provide on the two types of power of attorney.
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This was not met as evidenced by: a resident was not able to leave the facility without the staff confirming it with the power of attorney. This poses a potential threat to the care and supervision of residents.
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Corrected this from a previous citation issued on 08/19/2025.
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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: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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
07/17/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250717092158

FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:ALEXIS THACKERFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRIVETELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: 47DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tony SellersTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Medication not given as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Kerry Hiratsuka conducted this unannounced complaint visit to deliver the results of the allegation above.

LPA reviewed facility records, records submitted by the complainant, and conducted interviews. The facility records and staff interviews show the facility followed medication orders and the resident refused medications. Relevant party interviews conducted stated the facility staff did not follow medication changes presented to the facility and overdosed the resident. The relevant interviews stated the facility staff gave the incorrect dose of the medication upon move-in and the entire stay. One staff interview stated the resident’s medication was decreased after about a week because the resident didn’t tolerate the increase, but the facility records do not show there was a change. The facility did not produce any records of the facility contacting the doctor requesting a change in the medication dose.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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-20250717092158
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: 10/22/2025
NARRATIVE
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A review of the medication orders the facility has showed the resident had a prescription for 5mg of a medication that was to increase to 10mg after 30 days. Per the records the resident started the 5mg prior to moving into the facility and the 10mg started shortly after the resident moved in per the prescription. There was an entry made by someone at the facility in the computer program the facility uses for medication that changed the order to 5mg, but there was no medication order in the resident’s file indicating the prescription change. The medication administrator record (MAR), which the staff have to log in the dosage of medication given to the resident shows they never stopped giving the 10mg dose until a written doctor’s order came in changing the medication to 5mg. The MAR dosage was based on the original doctor’s order of 10mg. LPA is unable to contact the person who made the medication change in the computer.

Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is 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.

No citations were issued for this report
Exit interview was conducted with facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5