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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005531
Report Date: 05/17/2021
Date Signed: 05/17/2021 10:38:37 AM



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
09/30/2020 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200930090639
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: 31DATE:
05/17/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lynda Murray, Director of Health and WellnessTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Resident pushed by another resident resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Melissa Lusby arrived at the facility on Monday May 17, 2021 to deliver findings for the complaint investigation. LPA wore an N95 as part of covid-19 precautions. LPA identified herself and discussed the elements of the allegation.
Based on interviews conducted and documents reviewed, the Department finds the preponderance of evidence standard was not met.

Throughout the course of the investigation, the following documents were reviewed: R1 and R2's care plan, physicians report, nursing notes, and incident report. LPA also reviewed staffing schedules and conducted staff interviews. LPA learned that R1 had an unwittnessed fall and also had a history of claiming others were hurting her. While the above allegation may have happened, LPA determined that there was not a lack of staffing which would have resulted in neglect/lack of supervision.
Unsubstantiated
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: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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-20200930090639
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: 05/17/2021
NARRATIVE
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As a result of this investigation LPA finds allegation to be UNSUBSTANTIATED - A finding that the complaint is 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.

Exit interview conducted. Appeal rights were given. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2