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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700012
Report Date: 08/14/2020
Date Signed: 08/14/2020 11:18:41 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200420114316
FACILITY NAME:TWIN RIVERS AT NATOMASFACILITY NUMBER:
342700012
ADMINISTRATOR:VADAREVU, SITAFACILITY TYPE:
740
ADDRESS:421 SAN JUAN ROADTELEPHONE:
(916) 216-3058
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:48CENSUS: 31DATE:
08/14/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sita VadarevuTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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9
Caregiver did not have the training to respond to an emergency.
INVESTIGATION FINDINGS:
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On August 14, 2020, 11:00 at AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to commence a complaint investigation finding due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegation with Sita Vadarevu, administrator.

On 4/3/2020, Community Care Licensing (CCL) received an Unusual Incident/Injury Report. The report indicates that a trespasser was found on the property at 4 AM and law enforcement was called immediately. Complainant stated the facility did not provide proper training on how to respond to an emergency to the staff (S1) that was working the night of the incident. Complainant stated S1 did not call 911 immediately.

During the complaint investigation, LPA Keosavang obtained pertinent documents such as a copy of residents’ physician report, residents’ care plan, staff roster, staff trainings, and police report. Based on investigation conducted by the Department that included interviews with facility’s staff and residents. Administrator stated training was provided to all staff.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
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 4
Control Number 27-AS-20200420114316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TWIN RIVERS AT NATOMAS
FACILITY NUMBER: 342700012
VISIT DATE: 08/14/2020
NARRATIVE
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Based on the training records that was obtained by LPA, S1 had attended a Med-Tech in-service training on 2/21/2020. One of the training topics that was provided to all staff was how to deal with emergencies (review procedures and policies in the Med room resource binder on what needs to get done, know where the gas emergency valves are located, electrical shut off in the fire panel room). S2 stated there is a manual book located in the med room which is another source of training for staff. S2 stated staff that works the NOC shift are required to get familiar with the manual book before being assigned to work a NOC shift. According to S2, the manual book has information on how to respond to emergencies and when to call law enforcement. LPA reviewed a copy of the manual book and observed the facility’s protocol on calling law enforcement in an emergency. In the manual book it states for emergency, always call 911, they can be here within minutes. They can help you assist with many situations such as medical emergencies, fire, break-ins, psychiatric emergencies, etc. Sacramento County non-emergency police telephone number and Sacramento City non-emergency police telephone number was in the manual book. According to the police report, officers responded to a call at approximately 4:13 AM and arrived at the facility at approximately 4:16 AM. Resident (R1) stated S1 responded in a timely manner and acted accordingly by calling law enforcement. R1 stated officers arrive shortly after and took R1’s statement before leaving the facility.

Based on statement and documents provided. This agency has investigated the complaint alleging, caregiver did not have the training to respond to an emergency. The Department have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200420114316

FACILITY NAME:TWIN RIVERS AT NATOMASFACILITY NUMBER:
342700012
ADMINISTRATOR:VADAREVU, SITAFACILITY TYPE:
740
ADDRESS:421 SAN JUAN ROADTELEPHONE:
(916) 216-3058
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:48CENSUS: 31DATE:
08/14/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sita VadarevuTIME COMPLETED:
11:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is not providing adequate supervision at night.
INVESTIGATION FINDINGS:
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On August 14,2020, at 11:00 AM, Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone to commence a complaint investigation finding due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegation with Sita Vadarevu, administrator.

Regarding the allegation, licensee is not providing adequate supervision at night.

During the complaint investigation, LPA Keosavang obtained pertinent documents such as a copy of residents’ physician report, residents’ care plan, and staff roster. LPA interviewed the administrator regarding the above allegation. Administrator stated the facility has a total of 34 residents. There is a total of 5 incontinence residents. There is only 1 staff assigned to work the NOC shift to care for all 34 residents. LPA received statements from 2 staff and 4 residents. LPA interviewed staff (S2) and asked if there has been an issue with staffing during the NOC shift. S2 stated S2 works the AM shift, but sometime picks up the NOC shift. S2 stated when it gets busy, and things happen the facility do need another staff on hand.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20200420114316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TWIN RIVERS AT NATOMAS
FACILITY NUMBER: 342700012
VISIT DATE: 08/14/2020
NARRATIVE
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S2 said the NOC shift is mellow and as of right now it is ok to have one staff working the NOC shift. LPA asked S3 if the facility is providing adequate supervision at night. S3 answered there is only 1 staff working at night. S3 stated “it’s not enough”. S3 believes there should be at least 2 staff working the NOC shift to provide care for all residents. Based on interviews with 4 residents, it was discovered that 3 residents out of 4 thinks the facility should have at least 2 staff working the NOC shift. Resident (R1) stated that the facility is providing adequate supervision at night. R1 said there is enough staff at night. R1 stated almost all of the residents are sleeping at night so having one staff is enough. R3 stated staff comes every 2 hours to assist with changing. When asked if staff responds in a timely manner when R3 needs assistance. R3 answered yes staff respond and tries to come to assist R3 as soon as they can. Joan Peterson, Administrator, stated 1 staff working the NOC shift is enough because it’s a very easy shift. The facility has no total care residents and the staff working the NOC shift just must make rounds, check on residents, do laundry, and assist with 4-5 residents that needs changing throughout the night.

The Department has investigated the complaint. Although the allegation may have happened or is valid, therefore the allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4