342700202-4-30-2024-59-AS-LMUZ-D4VVXM-20240502164946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 04/23/2024
Date Signed: 04/30/2024 02:08:04 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
09/13/2023 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230913151016

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: 77	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Annoinette Edwards, Executive Director		TIME COMPLETED:	03:01 PM

ALLEGATION(S):

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Resident caused injury to another resident in care due to inadequate staffing.

INVESTIGATION FINDINGS:

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Amend: To change confidential to Public and change findings to UNSUBSTANTIATE.

On April 23, 2024, Licensing Program Analyst (LPA) arrived unannounced to deliver finding for complaint # 59-AS-2023091315101. LPA met with Ms. Edwards and explained the reason for the visit.
During the investigation, LPA interviewed the Executive Director, 2 care staff that worked the night of the incident and (1) residents. LPA also reviewed documentation regarding staffing levels. The results of the investigation are as follows:

In Memory Care, staff indicated they are fully staffed and have been for some time. Staff also stated only a few residents require more assistance and there have been (4) staff scheduled on PM shifts, but it really depends on how well staff work together. A second staff stated they are not understaffed. This occurrence would have happened even if they were fully staffed. The Executive Director also stated that they have a ratio and are following those directives. All staff who were interviewed indicated residents care needs are being 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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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-20230913151016

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: 04/23/2024

NARRATIVE

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Based on information obtained, this incident was not witnessed by any staff or another resident. LPA finds the allegation that resident caused injury to another resident in care due to inadequate staffing to be UNSUBSTANTIATED. An unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allege violation occurred.

Per California Code of Regulations, Title 22, no citations were issued.
An exit interview was conducted and a copy of this report was given to Ms. Edwards.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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