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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005531
Report Date: 09/23/2020
Date Signed: 09/23/2020 12:09:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
317005531
ADMINISTRATOR:PERKINS, JOYCEFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRTELEPHONE:
(530) 887-8600
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: DATE:
09/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Joyce Perkins TIME COMPLETED:
12:10 PM
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On September 23, 2020, Licensing Program Analyst (LPA) Sarena Keosavang contacted administrator, Joyce Perkins, via telephone to obtain additional information regarding an incident that occurred at the facility on 09/18/2020. This visit was conducted via telephone due to COVID-19 and pre-cautionary measures.

The purpose of the telephone call was to follow-up on an Unusual Incident/Injury Report that was submitted to Community Care Licensing (CCL). This report indicated that R1 reported that caregiver had slapped R1 with a motion of open palm sweeping upwards onto forehead.

LPA interviewed administrator regarding the report submitted to CCL. The interview with administrator indicates that R1 and R2 are both married and reside at the facility. The day of the incident occurred caregiver was assisting R1 into bed while R2 was on the phone with their son. R1's son heard R1 through the phone saying, "She slapped me." R1's son reported the incident to administrator. Administrator investigated and received statement from caregiver. Administrator stated caregiver was suspended until further notice. Ombudsman had been notified via text and phone messaged left on 9/20/2020. LPA requested for R1's physician report, needs and services plan, and caregiver's written statement of the incident.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the administrator, Joyce Perkins, and was advised that a signed copy of the report shall be emailed to LPA.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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