342700202-10-5-2022-25-AS-LMUZ-CJXP4N-20221006105925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:07:31 AM

Unsubstantiated

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
05/17/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220517140547

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	KAYLA DAVIS		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS:	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Kayla Davis, Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility infested with rodents
Resident's apartment smells of urine

INVESTIGATION FINDINGS:

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On October 5, 2022, at 8:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for Complaint # AS-202205171405475. LPA met with , Executive Director, Kayla Davis and explained purpose of the visit.

Prior to initiating the inspection LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE). Additionally, LPA was screened by the front desk personnel upon arrival.

The Department received a complaint alleging the facility has pest, theft of Resident's money and property, Resident's apartment smells of urine and Resident received black eye and bruises while in care. LPA reviewed resident files and interviewed 10 staff and residents.
To continue see 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 25-AS-20220517140547

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: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 10/05/2022

NARRATIVE

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Allegation findings are as follows:
Facility has pests:
The facility learned about a pest problem. On May 10, 2022, the facility staff called a pest control company to come and check the building. Documentation indicated pest control company did not find any signs of mice or droppings during their checks but set out traps. Based on interviews conducted and records reviewed. no mice were caught in the traps. The facility is located across the street from a large open undeveloped field and a creek along the side of the facility therefore there has been occasions when pest have been seen at the facility. The facility has been pro-active to minimize the problem. LPA reviewed invoices of service every month since November 2021 to current. Based on interviews and review of service record invoices, the Department finds that the allegation that facility has pests, is UNSUBSTANTIATED, meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Resident's apartment smells of urine
LPA interview 3 medical staff who stated R1 was starting to decline with incontinence needs and more care was needed. 6 other staff members interviewed stated they never smelled urine in the resident’s room and the resident’s bed was always made. At the time LPA toured the facility, R1 had already moved out therefore Based on the staff statements, and LPA was unable to observe if R1's room had a urine odor, the allegation is UNSUBSTANTIATED, meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

To continue See 9099-A

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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, 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
05/17/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220517140547

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	KAYLA DAVIS		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS:	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Kayla Davis, Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident received black eye and bruises while in care
Theft of Resident's money and property

INVESTIGATION FINDINGS:

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Allegation findings are as follows:
Resident received black eye and bruises while in care
LPA interviewed 3 medical staff that stated R1 was a fall risk. Staff recall observing R1 trying to get out of bed and fell between the bed and the wheelchair. R1 hit her face on the arm of the wheelchair before falling to the floor. R1 was treated at that time for the fall. R1's fall resulted in R1 sustaining a black eye. Facility staff were present during R1's fall however were unable to prevent R1 hitting the arm of her wheelchair. Facility staff provided timely medical attention at the time of R1's fall. Based on the investigation, R1's back eye was not a result of a lack of care and supervision however, R1 sustained a black eye and bruises due to a fall at the facility therefore the allegation is SUBSTANTIATED, meaning the preponderance of evidence standards have been met. Although this allegation is substantiated, citations are not issued as the allegation was not a result of a violation of Title 22 regulations.

To continue see 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 25-AS-20220517140547

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: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 10/05/2022

NARRATIVE

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Allegation findings are as follows:
Theft of Resident's money and property
Based on interviews conducted, it was reported that an agency staff stole R1's money and property from R1's apartment. A police report was filed regarding the incident however, the resident did not want to press charges. R1's ATM card was used at a Mall in Fairfield CA. The employee signed for the merchandise while in the Mall. The employee was hired by the facility from an outside agency. Once the facility learned of the theft, the staff was terminated from working at the facility. The allegation is SUBSTANTIATED, meaning the preponderance of evidence standards has been met.
Although this allegation is substantiated, citations are not issued as the allegation was not a result of a violation of Title 22 regulations.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to Kayla Davis.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4