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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 08/21/2023
Date Signed: 08/21/2023 02:06:23 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, 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
04/06/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230406092716
FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KENT MULKEYFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 102DATE:
08/21/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director Antonette EdwardsTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff does not provide adequate supervision resulting in resident sustaining multiple falls.
Resident sustained a Urinary Tract Infection while in care.
Staff did not seek medical attention to resident in a timely manner.
Staff did not answer resident's call butoon in a timely manner.
INVESTIGATION FINDINGS:
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On 08/21/23, Licensing Program Analyst (LPA) Talwinder Bains 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**
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023
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-20230406092716
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: 08/21/2023
NARRATIVE
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During the investigation, the Department reviewed records including but not limited to, hospital records, client records, facility documents and interviews.

Allegation: Resident sustained a Urinary Tract Infection while in care. A records review for R1 indicated that R1 was diagnosed with Urinary Tract Infection during their ER visit on 10/19/21. Record review and interviews did not indicate any negligence by facility which could have been contributed to R1 having Urinary Tract Infection. Based on this information, this allegation is found to be UNSUBSTANTIATED.

Allegation: Staff did not answer resident's call button in a timely manner. The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond to their call buttons in timely manner however sometimes there is a delay in response due to staff assisting other resident’s needs. During call button log review, department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is ‘staff are not responding to call buttons in a timely manner ‘is found to be UNSUBSTANTIATED.

Allegations: Staff does not provide adequate supervision resulting in resident sustaining multiple falls and Staff did not seek medical attention to resident in a timely manner.

R1 was admitted to the facility on 09/05/21 and transferred to a local hospital after a fall incident which occurred on 10/19/21. Records review for R1 indicated that R1 fell multiple times over several days prior to their fall which occurred on 10/19/21. No major injuries were noted by facility staff for the falls prior to 10/19/21. Based on interviews, R1 lost their balance and fell on 10/19/2021. Medical records indicated that R1 did not remember to use their walker and did not remember to ask for help. Record review indicated that R1 experienced multiple falls at facility where facility provide care and supervision to R1 per their care and service plan. Furthermore, facility notified R1’s responsible parties, CCL, physician and took appropriate measures to mitigate fall incidents to R1. Additionally, it has been concluded that the falls R1 sustained were due to R1's medical condition and not due to a lack of care or supervision provided by the facility. The facility responded appropriately to these falls by providing the necessary care and assistance to R1 and seeking medical help when needed by calling 9-1-1. Record review indicated that R1 was transferred to local hospital after R1 sustained a fall on 10/19/21 to seek appropriate medical care. It was noted from the record review, hospital records and medical records indicated that R1 had a high risk of falls due to their medical complications. Based on these findings, the falls occurred as a result of R1's medical condition, and the facility provided appropriate care and assistance in response to these incidents therefore, this allegation is UNSUBSTANIATED.

Based on interviews conducted and documentation reviewed, all above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No citations were cited during this visit. Exit interview conducted and copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
04/06/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230406092716

FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KENT MULKEYFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 102DATE:
08/21/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director Antonette EdwardsTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident became septic while in care.
INVESTIGATION FINDINGS:
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On 08/21/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director Antonette Edwards.

Allegation: Resident became septic while in care.

Based on medical records review for R1, there is no indication R1 became septic. There is no other information available for review during the investigation that indicates R1 became septic while residing at the facility. Based on this information, this allegation is found to be UNFOUNDED.

A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No citations were issued today. Exit meeting conducted. A copy of this report has been provided to facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023
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 3