342700202-8-7-2023-59-AS-LMUZ-CUPT4P-20230814142416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 08/07/2023
Date Signed: 08/07/2023 01:09:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230417141659

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: 105	DATE:	08/07/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Executive Director Antonette Edwards		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility is falsifying staffing schedule.

INVESTIGATION FINDINGS:

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On 8/7/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director Antonette Edwards.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230417141659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 08/07/2023

NARRATIVE

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Allegation: Facility is falsifying staffing schedule.

LPA interviewed staff, reviewed employee files, and facility records to investigate this allegation. LPA found out that facility was falsifying facility staff records.
Per the medication administration records (MAR), it was documented that S1 administered insulin to R1 on 5/5/23, however, based on memory care schedule and S1’s timesheet, S1 had a day off on 5/5/23.

Additionally, facility listed S2 on memory care schedules to reflect that facility was meeting staffing ratio requirements per the stipulation agreement adopted on January 5, 2023. Based on stipulation agreement, the facility is required to have (3) three direct care staff working AM and PM shifts and (2) two direct care staff working NOC shifts. Based on staffing schedules reviewed, facility listed S2 on the schedule April 1, 2, 3, 7, 8, 14, 15, 21, 22, 28, and 29 as a direct care staff for memory care. S2 is facility management and staff interviews indicated that S2 was not working in a direct care staff capacity during the listed dates above. Furthermore, facility could not provide sufficient documentation that S2 worked at the facility during the dates above as S2 is a salary employee and no timesheets are generated. Based on the information obtained. The facility falsified staffing records therefore LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230417141659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/08/2023 Section Cited CCR 80012(a)	1 2 3 4 5 6 7	80012 False Claims (a)No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee shall submit a plan to the department how the facility will ensure staffing ratios are met in the memory care unit. In addition, the facility shall submit staffing plans with timesheet entries for all staff who work in the memory care unit for the next 90 days. Facility shall submit POC by due date 8/8/23.
	8 9 10 11 12 13 14	Based on records review and interviews conducted, the facility falsified staffing schedules in regard to staffing schedule, staffing and actual hours worked which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC9099 (FAS) - (06/04)

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