342700202-6-1-2023-59-AS-KHOS-CSJPWL-20230606114054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 06/01/2023
Date Signed: 06/01/2023 06:06:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
03/07/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230307105003

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	KENT MULKEY		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS: 65	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Desiree Tawney, Business Office Manager		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Facility is not following Covid-19 reporting protocols.
Facility is not following Covid-19 masking protocols.
Facility is not following Covid-19 quarantining/isolation protocols.
Facility does not have enough staff to meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude and deliver findings to a complaint investigation. LPA met with Desiree Tawney, Business Office Manager, as Administrator was not at the facility.

During the investigation, LPA interviewed the Executive Director, Memory Care Coordinator and Resident Care Coordinator. LPA also toured the Assisted Living and Memory Care units, including the dining room and activity areas, and reviewed staffing schedules. The results of the investigation are as follows:

Allegation: Facility is not following Covid-19 reporting protocols.

Memory Care Coordinator (MCC) stated on 3/8/23 she reported the initial 4 staff and 6 resident cases to (3) people at local public health She also reported to LPA Tryon. MCC reported she reported an additional (5) cases on 3/6/23.
cont on 9099C-1...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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 3

Control Number 59-AS-20230307105003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 06/01/2023

NARRATIVE

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9099C(1)..MCC stated that as of Tuesday, 3/7/23, there were (16) cases. In addition, MCC confirmed that Home Health agency has been advised of the positive cases.

Department records show that on 3/3/23, the facility called the Department and reported an outbreak of 6 residents and 4 staff. The phone conversation notes indicate that county public health had also been notified. Department records, dated 3/8/23, document additional cases

On 3/8/23, LPA was made aware of additional cases by the Administrator who stated there are 18 resident cases and 4 staff cases per his knowledge and all resident cases are from Assisted Living and are currently quarantining.

Administrator stated that Sac County public health sent their Covid log template to the prior Administrator's email and he did not receive the email until 3/6/23 when it was forwarded to him.

Based on information obtained from interviews and documentation, it appears the facility reported timely to local public health, home health and to the Department, as required, and the allegation is found to be 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.

Allegation: Facility is not following Covid-19 masking protocols.

LPA observed on 3/8/23 all staff to be wearing an N95 mask. The Administrator confirmed that staff is asking "everyone to screen themselves, wear a mask and don't visit if showing signs or symptoms". A family member interviewed during this time frame stated staff was wearing personal masks at all times. LPA observed many boxes of N95 masks on hand on 3/8/23.

Based on information obtained, LPA finds the allegation to be 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.

cont on 9099C-2..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230307105003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 06/01/2023

NARRATIVE

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9099C-2.. Allegation: Facility is not following Covid-19 quarantining/isolation protocols.

On 3/8/23, LPA observed signage in Assisted Living Unit showing that the dining room, activities and salon were closed. LPA also observed several PPE carts with supplies located near isolation rooms. LPA took several photos. LPA observed signage to be posted on each individual door- stating "Covid-19 Quarantine in Progress" and also indicated a "start date" and "end date" of the quarantine period.

Based on information obtained, LPA finds the allegation to be 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.

Allegation: Facility does not have enough staff to meet resident's needs.

Department documentation, dated 3/3/23, notes that the facility indicated there were no staffing needs at the onset of the outbreak. Administrator stated on 3/8/23 they do have adequate staffing coverage at this time and managers will fill in if they are short staffed. LPA reviewed staffing schedules for February and March 2023 and observed that 3-5 caregivers were scheduled in Assisted Living on the "am" shift, at least (3) caregivers were scheduled on the "pm" shift and 1-2 caregivers on the "NOC" shift. In additional, there is always (1) nurse and/or (1) Med-Tech on each shift.

Based on information obtained, LPA finds the allegation to be 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.

Exit interview with Business Office Manager . Copy of report provided to facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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