317001368-10-24-2024-59-AS-KHOS-DBCL9X-20241125073417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317001368
Report Date: 10/23/2024
Date Signed: 10/24/2024 10:34:12 AM

Unsubstantiated

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
03/22/2024 and conducted by Evaluator Todd Tryon

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240322160247

FACILITY NAME:	THREE PINES ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	317001368
ADMINISTRATOR:	SEISA, CUSTODIO A.		FACILITY TYPE:	735
ADDRESS:	1450 OAK RIDGE WAY		TELEPHONE:	(530) 885-5181
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	6	CENSUS: 6	DATE:	10/23/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joel Seisa, Licensee/Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents forced to eat more they wish to.
Resident used as staff to assist other client's with bathing

INVESTIGATION FINDINGS:

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On 10/23/2024 LPA Tryon visited the facility to complete the complaint. LPA met with Joel Seisa.
During the course of the investigation LPA has spoken with staff, Administrator and residents, as well as reviewed facility records.
Regarding the allegation that residents were forced to eat more than they wish to, LPA spoke with residents and staff. LPA learned that resident R1 was concerned about weight, and did not always want to eat meals or complete meals. LPA learned that staff did encourage R1 to eat meals, but staff involved maintains that she never forced R1 to eat; but simply encouraged, especially since medications were to be given with food. R1 claimed that staff forced R1 to eat. Since there is a difference in accounts of the situation, LPA is not able to ascertain whether staff actually insisted that R1 eat; or simply encouraged. LPA finds the allegation to be unsubstantiated.
Regarding resident being used as staff to assist other clients with bathing, again, the accounts differ from witness to witness. Resident stated that staff asked her to help others with showers; staff involved stated she asked R1 NOT to go into the bathroom when others were showering; that R1 took it upon self to (cont)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 59-AS-20240322160247

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: THREE PINES ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 317001368
	VISIT DATE: 10/23/2024

NARRATIVE

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assist others to shower. Staff involved said she did ask R1 to take a towel to the other resident, but did not ask her to go into the room and help. Other resident denied that R1 helped in the shower.
Again, due to differences in accounts, LPA is not able to ascertain whether the resident was actually asked by staff to help the others in the shower; or if R1 made the decision to help. Therefore, 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.

Appeal rights provided, exit interview conducted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC9099 (FAS) - (06/04)

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