342700202-8-13-2023-27-AS-DAWL-CUNVRV-20230813164033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 04/28/2021
Date Signed: 08/13/2023 04:40:32 PM

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
10/09/2020 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201009154327

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	MELISA TIBURCIO		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS: 60	DATE:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	03:51 PM
MET WITH:	Kayla Davis, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility denied family member access to resident which has directly caused the resident's health to deteriorate.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On April 28, 2021, at 3:50pm Licensing Program Analyst (LPA) DeAnna Williams-Lyons delivered finding for a complaint the department received on 10/13/2021. LPA spoke with Kayla Davis, the Executive Director, and explained the reason for the televisit.

During the investigation, LPA conducted interviews and reviewed documentation including, but not limited to, Admission Agreement, resident's physician's report and a physician’s order from resident’s doctor. The results of the investigation are as follows:
Interviews conducted and documentation reviewed confirmed R1 requested several times to receive visits with family to assist with R1’s finances. All requests made were denied by the facility based on Covid-19 processionary measure and Department’s COVID 19 visitation guidance. The facility advised the resident and resident’s responsible party based on COVID 19 precautionary measures, visitors, other than medical professionals, were not being allowed to visit residents at that time.

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: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

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 2

Control Number 27-AS-20201009154327

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: 04/28/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 had window visits from family however, it was observed that R1’s health started to deteriorate. R1 was seen by primary care physician on October 9, 2020. According to resident’s physician, resident’s health was starting to deteriorate. On October 9, 2020, R1’s physician wrote a letter to the facility instructing the facility to allow resident to have visits in resident’s apartment. LPA spoke with the executive director on October 10, 2020 asking if visits are currently being denied. Executive Director confirmed the facility was not allowing visits to occur based on California Department of Social Services current Covid-19 guidelines. LPA instructed the executive director to allow the visits to occur based on R1’s physician’s order. The physician’s order was submitted to the executive director and to LPA on October 9, 2020. R1 was granted visitation.

This agency has investigated the complaint alleging Facility staff denied family member access to resident which has directly caused the resident’s health to deteriorate 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 did or did not occur.

Exit interview conducted. Copy of report sent to ED via e-mail, LPA requests that ED prints out report, signs it, and faxes and/or emails a signed copy to Community Care Licensing. A signed copy should also be retained for facility's records.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2