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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317001368
Report Date: 11/04/2024
Date Signed: 11/04/2024 02:59:25 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
04/11/2024 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240411150538
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: 6DATE:
11/04/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lisa Varela, StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not properly supervise resident as stated in the individual program plan
INVESTIGATION FINDINGS:
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On 11/4/2024 LPA Tryon visited the facility to complete the complaint. LPA met with Lisa Varela. LPA spoke with Administrator Chris Chu by telephone; he agreed to have staff LIsa sign the report.
During the course of the investigation LPA has reviewed facility records, Admission Agreement, IPP, Conservatorship documents, interviewed residents and staff, reviewed law enforcement report.
Regarding the allegation that facility staff did not properly supervise resident as stated in the individual program plan, LPA reviewed IPP, conservatorship document, interview resident and staff. LPA learned that the Licensee did drop R1 and another resident at a church on 3/17/2024 to attend a Bible study group. LIcensee left the church, and left residents to the supervision of the person heading the group. R1 had alleged that another male client from another facility had touched her private area. Police report found that investigating officer did not believe probable cause existed for any crime. However, at this time, it appears that the facility did not follow the IPP that states resident "must have supervision 100% of the time by staff from her care home." Therefore, the allegation is found to be substantiated. A finding of substantiated means that the allegation is valid because a preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
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 3
Control Number 59-AS-20240411150538
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
85078(a)(1)
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(a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. The facility failed to meet this requirement as evidenced by: through review of documents and staff and resident
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Administrator will devise a plan of how this type of situation will be dealt with in the future. Plan to be submitted to CCL by 11/5/2024.
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interview, LPA learned that care home staff dropped resident R1 at church to attend a church group. Staff did not stay to supervise, but left R1 to the supervision of a non-staff. As per R1's IPP "must have supervision 100% of the time by staff from her care home."
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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: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC9099 (FAS) - (06/04)
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