317005531-7-28-2021-27-AS-MSEY-C5CVPF-20210728163640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005531
Report Date: 07/28/2021
Date Signed: 07/28/2021 12:58:02 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
02/23/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20210223085033

FACILITY NAME:	SIERRA RIDGE SENIOR LIVING		FACILITY NUMBER:	317005531
ADMINISTRATOR:	JOE DUNHAM		FACILITY TYPE:	740
ADDRESS:	3265 BLUE OAKS DR		TELEPHONE:	(530) 887-8600
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	65	CENSUS: 33	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Lynda Murray, Nurse		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility did not manage resident's medications.
Facility did not timely provide a copy of incident report to resident's responsible person.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with Lynda Murray during today’s complaint investigation. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff, upon entering the facility.
LPA investigated allegation, "Facility did not manage residents medications". LPA reviewed resident records and interviewed staff. Through documentation LPA observed resident R1 was released from a skilled nursing facility back to the Sierra ridge on 10/13/20. Facility received a medication list from the nursing facility and then from primary care physician on 10/13/20.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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 6

Control Number 27-AS-20210223085033

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: 07/28/2021

NARRATIVE

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LPA reviewed R1's MAR in which it states a PRN pain medication was started on 10/15/20. LPA observed resident notes, in which it documents each time resident complained of pain and that a PRN medication was provided. LPA observed a order from an orthopedics office dated on 10/14/20 and confirms order was faxed and received by facility on 10/14/20. The order stated R1 is to take Aspirin 325 mg 1 tab every day until 6 weeks post-op. LPA reviewed R1's MAR and observed Aspirin 325 mg was not started until 10/21/20. LPA reviewed R1's notes and there is no documentation on why facility waited until 10/21/20 to provide R1 the prescribed medication. Due to the information gathered. LPA finds allegation to be SUBSTANTIATED.
LPA investigated the allegation, "Facility did not timely provide a copy of incident report to resident's responsible person". LPA conducted a record review and interviews. The department interviewed responsible party in which they stated they requested resident records on 10/5/20, 11/18/20, and 12/2/20 and was not supplied all resident records until February 4, 2021. LPA reviewed facility documents and observed a request for resident records dated on 10/4/20 and 12/15/20 from responsible party. LPA observed facility staff sent responsible party discharge paperwork only on 12/17/20 and sent the remaining requested documentation on February 3, 2021 via mail carrier. LPA finds facility eventually released requested resident documentation to responsible party however it was not in a timely manner. LPA finds allegation to be SUBSTANTIATED.

Deficiencies cited on 9099-D. Appeal rights given. Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20210223085033

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: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/29/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Facility agrees to conduct a training with all staff that manage medication on medication documentation and physician orders.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review the licensee did not manage R1's medications properly which poses an immediate health and safety risk to resident's in care.	8 9 10 11 12 13 14	Administrator to send into CCL by 7/29/20 the date of when training will take place. Once training is completed, administrator to send training documents into CCL.
Type B 08/06/2021 Section Cited CCR 87468.1(a)(9)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately.	1 2 3 4 5 6 7	Facility agrees to complete and send into CCL a policy of communication with responsible parties. Policy to be sent into CCL by 8/6/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interviews the licensee did not have prompt and appropriate communication with responsible party.	8 9 10 11 12 13 14

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
02/23/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20210223085033

FACILITY NAME:	SIERRA RIDGE SENIOR LIVING		FACILITY NUMBER:	317005531
ADMINISTRATOR:	JOE DUNHAM		FACILITY TYPE:	740
ADDRESS:	3265 BLUE OAKS DR		TELEPHONE:	(530) 887-8600
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	65	CENSUS: 33	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Lynda Murray, Nurse		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Incomplete resident records
Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with Lynda Murray during today’s complaint investigation. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff, upon entering the facility.
LPA investigated allegation, "Incomplete resident records". LPA reviewed 3 resident records and found records to be complete with all required documentation. Due to the information gathered LPA finds allegation to be UNFOUNDED.
LPA investigated the allegation, "Personal Rights". The department interviewed relevant party and did not find any accusations of resident's person rights being violated. LPA finds allegation to be UNFOUNDED.
Exit interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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 6

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
02/23/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20210223085033

FACILITY NAME:	SIERRA RIDGE SENIOR LIVING		FACILITY NUMBER:	317005531
ADMINISTRATOR:	JOE DUNHAM		FACILITY TYPE:	740
ADDRESS:	3265 BLUE OAKS DR		TELEPHONE:	(530) 887-8600
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	65	CENSUS: 33	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Lynda Murray, Nurse		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility did not follow reappraisal guidelines
Facility released confidential information.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with Lynda Murray during today’s complaint investigation. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff, upon entering the facility.
LPA investigated allegation, "Facility did not follow reappraisal guidelines". LPA conducted a record review and conducted interviews. LPA observed through documentation R1 returned to the facility from a stay at a skilled nursing facility(SNF) on 10/13/20. Documentation shows a reassessment at the SNF from facility nurse occurred on 10/9/20. A new service plan was completed on 10/12/20 for R1 and a new physician report was obtained dated on 10/08/20.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20210223085033

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: 07/28/2021

NARRATIVE

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The department interviewed relevant party in which they stated they were not made aware of the new service plan and if there were any changes. Interviews with staff state they would have provided service plan to relevant party but did not have any documentation to show the service plan was provided. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated the allegation, "Facility released confidential information." Interviews were conducted with relevant party in which they had concerns with confidential information being provided to unauthorized individuals. LPA interviewed staff and administrator in which they stated they do not recall a time confidential information was released to an unauthorized individual. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

Exit interviewed conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6