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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005531
Report Date: 04/29/2021
Date Signed: 04/29/2021 01:25:08 PM



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 Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210104092301
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: 33DATE:
04/29/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joe DunhamTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff mismanaging resident's medication


INVESTIGATION FINDINGS:
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Licensing Program Analyst Melissa Lusby contacted the facility via telephone to deliver findings for the complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations. The Department reviewed facility notes, resident file, and conducted relevant party interviews, obtained relevant documentation and evidence.

The department notes that R1 had an unwitnessed fall on 12/25/2020. Family declined to send resident to the hospital intially. When resident began to vocalize pain, resident was transported to the hospital and diagnosed with a fractured humerus. Resident's chart notes that Physician is to be notified prior to any PRN medication dispensed. Through staff interviews, it was learned that staff was not notifying R1's physicians prior to dispensing

Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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 7
Control Number 27-AS-20210104092301
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 317005531
VISIT DATE: 04/29/2021
NARRATIVE
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Additionally, on an order dated 9/5/2020, a PRN for moderate to severe pain was signed by the physician with a note to inform the family of new medication. The POA of R1 was never notified.

As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

Exit Interview conducted. Appeal rights were given. Copy of this report provided to facility representative.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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 Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210104092301

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:
04/29/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joe DunhamTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility abandoned resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst Melissa Lusby contacted the facility via telephone to deliver findings for the complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations. The Department reviewed facility notes, resident file, and conducted relevant party interviews, obtained relevant documentation and evidence.

The department notes that R1 had an unwitnessed fall on 12/25/2020. Family declined to send resident to the hospital intially. When resident began to vocalize pain, resident was transported to the hospital and diagnosed with a fractured humerus. R1 returned to the facility after the family declined surgery. Facility then called 911 to return R1 to the hospital because the facility was unable to meet R1's needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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 7
Control Number 27-AS-20210104092301
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 317005531
VISIT DATE: 04/29/2021
NARRATIVE
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The Department finds the allegation of facility abandoning resident to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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 Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210104092301

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:
04/29/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joe DunhamTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident fell while in care sustaining multiple fractures
INVESTIGATION FINDINGS:
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Licensing Program Analyst Melissa Lusby contacted the facility via telephone to deliver findings for the complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations. The Department reviewed facility notes, resident file, and conducted relevant party interviews, obtained relevant documentation and evidence.

R1's Service Agreement dated 12/26/2019, stated R1 is a fall risk. It was also noted on 1/24/2019, R1 does not need help with mobility and is independent with transfers. Per R1's Physicians Report dated 1/13/2020, R1 was able to bathe, dress/groom, feed, feed herself, and care for toileting needs independently. The department notes that R1 had an unwitnessed fall on 12/25/2020. Family declined to send resident to the hospital intially. When resident began to vocalize pain, resident was transported to the hospital and diagnosed with a fractured humerus.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20210104092301
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 317005531
VISIT DATE: 04/29/2021
NARRATIVE
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Based on document review and staff interviews, R1 had an unwitnessed fall which resulted in a fracture. The Department was unable to determine if lack of care and supervision resulted in R1 sustaining injuries.

Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Lusby conducted an exit interview.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 27-AS-20210104092301
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: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 317005531
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2021
Section Cited
CCR
87465(d)(1)
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Incidental Medical and Dental
(d) . . facility staff designated by the licensee, shall be permitted to assist the resident with self-administration . . .: (1) Facility staff shall contact the resident's physician prior to each
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Administrator to submit proof of scheduled training for all med techs regarding PRN authorization and proper protocol.
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dose . . . This requirement was not met as evidenced by staff interviews who acknowledged that the Physician was not contacted prior to PRN medications dispensed. This is a direct threat to the health and safety of the resident.
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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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7