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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005531
Report Date: 07/28/2021
Date Signed: 07/28/2021 12:59:40 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
12/23/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20201223114005
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:
07/28/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Linda Murray, NurseTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Lack of supervision resulting in residents engaging in physical altercations
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 the allegation, “Lack of supervision resulting in residents engaging in physical altercations”. LPA reviewed resident records, and interviewed facility staff. LPA observed R1 moved into the facility on 10/26/20 and had behaviors of exit seeking and anxiety upon move in. Facility documented daily on R1’s behaviors.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (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 5
Control Number 27-AS-20201223114005
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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On 10/29/20 it was documented twice that R1 was trying to harm other residents and staff but had no physical altercations. On 11/1/20 it was documented R1 was very agitated and got into an argument with another resident with R2. R1 had to spend the night in a different room in order to separate R1 and R2. On 11/7/20 it was documented R1 was anxious and upset with staff and other resident. On 11/8/2020 it was documented R1 badgered several residents. On 11/13/20 it was documented R1 slapped staff in the face. On 11/14/20 it was documented R1 was in altercation with R2, in which R2 pushed R1. On 11/16/20 it was documented R1 was badgering other residents until someone pushed R1 down, and R1 continued behavior. On 11/17/20 it was documented R1 was sent out to the hospital for aggression. On 11/18/20 R2 was moved into a different room then R1 however R1 did not return to the facility. LPA interviewed 2 staff members in which they stated R1 would get into other residents faces and become verbally aggressive. LPA reviewed facility care service plan for R1 dated effective on 10/19/20. LPA observed facility staff faxed primary care physician about R1’s behaviors. LPA found through record review and interviews R1 had aggressive behaviors toward residents and staff, however facility did not update residents needs and service plan and there is no documentation showing supervision was increased due to aggressive behaviors. R1 got into multiple altercations with other residents and two altercations resulting in R1 falling. Due to the information gathered LPA finds allegation to be SUBSTANTIATED.

Deficiencies cited on 9099-D. Appeal rights given. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (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 5
Control Number 27-AS-20201223114005
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
87705(c)(4)
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87705 Care of Persons with Dementia. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Facility agrees to send into CCL a policy on new admissions that show behaviors of aggression. Policy to be sent into CCL by 7/29/21.
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This requirement is not met as evidenced by: Based on record review and interviews the licensee did not provide sufficient supervision for R1 which poses an immediate health and safety risk to residents in care.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (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 5
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
12/23/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20201223114005

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:
07/28/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Lynda Murray, NurseTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility staff failed to follow resident's needs and care plan
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 the allegation “Facility staff failed to follow resident's needs and care plan.” LPA conducted a file review and interviewed relevant party and staff. Relevant party stated staff were to help resident with managing their hearing aides. LPA reviewed needs and service plan, in which it states resident has hearing aides but it did not document for staff to care for R1’s hearing aides. LPA observed in the facility notes on 11/3/20 that R1 was holding a hearing aide in their hand. LPA interviewed staff in which they stated they do manage hearing aides on a needs basis and could not remember if the staff managed R1's hearing aides. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (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 5
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
12/23/2020 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20201223114005

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:
07/28/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Lynda Murray, NurseTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility staff are not adequately trained
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 staff are not adequately trained”. LPA reviewed 5 staff training documents and interviewed staff. Interviews with staff stated they are provided training throughout the year online and in person. LPA reviewed 5 staff training documents for the year 2020 and found staff had the required training. Due to the information gathered LPA finds allegation to be UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (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 5