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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 02/02/2024
Date Signed: 02/02/2024 01:38:42 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
12/05/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231205081943
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: 44DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Business Office Director, Terri Henry TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff does not ensure facility is free of garbage.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint the Department received on December 5, 2023. LPA met with Business Office Director, Terri Henry, and Tina Garza, Marketing Direcgtor, and stated reason for the inspection. LPA stated she would be preparing today's report and then go over it in approximately an hour.

During the course of the investigation, LPA interviewed the Health and Services Director, Businsss Office Director and multiple care staff. LPA also toured the enclosed area where the large trash bins are located outside the facility and took several photographs on 12/7/23. LPA also observed a photograph that was taken just prior to 12/7/23 when the trash began piling up.

The results of the investigation are as follows:

cont on 9099C-1..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 59-AS-20231205081943
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: 02/02/2024
NARRATIVE
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9099C-1.. Allegation: Staff does not ensure facility is free of garbage. The complaint alleges the outside dumpster has been overly full for the past 2 weeks which is against the health and safety rules.

The Business Office Director (BOD) stated trash service is supposed to be provided several days per week, and confirmed there were (2) outside trash bins that "were full for one week and trash was piling up" in the back of the building. The BOD explained that the trash was not picked up for a week "due to late payment" and stated she called accounting right away once she was aware of the non-payment, and it took an additional (2) days for the payment to be processed. During this time, she requested extra pick ups from Thursday through Saturday, and by Monday, they were cleared.

The BOD explained how the city's Code Enforcement came out on 11/30/23 or on 12/1/23 and then again on 12/4/23 when they closed the case. The BOD stated Code Enforcement asked that all trash be removed by Monday, 12/4/23, and no citation was given.

All staff interviews confirmed there were recent concerns with trash piling up for days outside where the large trash bins are located. One staff stated the trash piled up for 1.5 weeks and this happened previously in Sept/Oct 2023 when trash didn't pick up. Another staff stated the trash was piling up 1.5 -2 weeks and "everyone knew". A third staff stated trash was piling up for approximately 1.5 weeks and it started on 11/20/23, the week of Thanksgiving, but has now been fixed. This staff stated the trash was flowing out on the sidewalk and Code Enforcement came out to cite. A fourth staff stated the trash was piling up for 5-6 weeks and consistently not picked up, and stated management already knew about it and was working on it.
LPA observed a photo shown to her by a staff member showing multiple filled trash bags and empty cardboard boxes sitting on the sidewalk area just outside the enclosed area where the large trash bins are.

Based on interviews conducted and information reviewed, LPA finds allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20231205081943
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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee/Administrato/Business Office Director agree to remind accounting on a monthly basis to ensure the trash bill is paid timely.

Documentation that a step has been taken to calendar the reminder- due by 2/3/2024.


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Based on interviews conducted and information obtained, the Licensee did not ensure that there was no trash overflowing from the enclosed area with the trash bins, onto the adjacent sidewalks, which presented an immediate health and safety risk to residents in care.
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There have been no subsequent issues with the trash pick since 12/4/23.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/05/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231205081943

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: 94DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Business Office Director, Terri Henry TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident's needs are not being met due to inadequate staffing.
INVESTIGATION FINDINGS:
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During the course of the investigation, LPA interviewed the Health and Services Director, multiple care staff and (3) residents. LPA also reviewed documentation relating to ADL's being provided and staffing levels. The results of the investigaton are as follows:

All residents indicated that it seems like the facility could use additional staffing as, lately, in January 2024, many caregivers are working double shifts. Residents also indicated that there are a few residents who require more assistance, as in needing a two-person assist with transferring, and if there are only (3) staff on duty that may not be sufficient, depending on how well the staff work together and communicate. Also, one resident stated that there have been (4) staff scheduled on a shift before, but it really depends on how well staff work together. All (3) residents who were interviewed indicated their care needs are being met as they are fairly independent with needing assistance.

cont on 9099A-C-1...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20231205081943
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: 02/02/2024
NARRATIVE
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9099A-C-1... All care staff interviewed indicated that there was one resident (R1), in particular, who would call for assistance very frequently which took staff away from the other residents. Also, interviews revealed that (R1) would also call right before or after a meal when staff was busy trying to get residents to the dining room. (R1) was also a two-person assist and if (2) of the (3) caregivers scheduled on the shift were on "light duty", then they are not able to assist in transferring (R1).

All staff interviewed stated that there hours were recently cut and that more staff is needed due to most staff being on "light duty", which means they are unable to assist with the most difficult residents, including (R1) or (R2).

One staff stated "other residents were waiting when (R1) was here" but they did receive the care they needed. This staff stated that "approximately 87% of the time, residents are getting their showers" , as she hears that showers are refused on the "pm" shift.

A second staff indicated she also doesn't think they are understaffed as resident showers are being given as scheduled. This staff stated there are (3) resident clusters that are "all about the same"- in cluster #1, there are (3) people always calling; in cluster #2, really just (R1); and in Cluster #3, upstairs, residents are fairly independent. (R1) recently was recently transferred to a skilled nursing facility. Many staff commented that they believe this is better placement for (R1) who needs more of 1:1 care. Another resident (R3) recently passed that was on hospice and this resident needed a lot of assistance also.

A third staff stated that "staff are tired when (R1) calls" and indicated there is "not enough staff even without (R1)" and confirmed that showers are being given.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview Copy of report provided to Business Office Director.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5