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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317001368
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:53:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/04/2021 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210104114658
FACILITY NAME:THREE PINES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
317001368
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:1450 OAK RIDGE WAYTELEPHONE:
(530) 885-5181
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chris ChuTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Medications are not locked.
INVESTIGATION FINDINGS:
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Arrived at the facility to complete the complaint. LPA met with Administrator Chris Chu. LPA had contacted the facility and screened to learn that there are no current COVID cases in the facility. LPA checked my own temperature, wore a surgical mask, and used hand sanitizer prior to the visit.
LPA has spoken with witnesses, staff, residents, reviewed records. Through interview LPA learned that prior to the COVID epidemic, the staff was leaving the morning dose of medication for resident R1 in an unlocked drawer in the kitchen so that she could take her own medication early in the morning when she was leaving early for her day program. Even though all the other medications in the house may have been secured in the office, there were a few pills unlocked in the drawer, that anyone could have potentially accessed. Therefore, the allegation that medications were not locked is SUBSTANTITATED. A finding of substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited as per Title 22 regulations. Exit interview conducted, appeal rights given to staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 27-AS-20210104114658
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: THREE PINES ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 317001368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited
CCR
80075(k)(1)
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The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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The facility will keep all medications in a safe and locked place that is not accessible to persons other than employees reponsible for the supervision of the centrally stored medication. The facility has already removed the medications from the drawer. The facility will develop a plan of how R1's medications will
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it was learned through interview that the facility staff was keeping morning medications for resident R1 in an unlocked drawer in the kitchen so that R1 would have access to the medications early in the morning before leaving for program. This is a potential health and safety hazard.
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be accessible to her and also secured and safe if she should return to program at a future date. Plan to be submitted to CCL by 11/4/21.
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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: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
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