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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:46:25 PM



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
11/05/2019 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20191105095006
FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:BRIGITTE LOESCHFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 57DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to ensure that resident had his oxygen tank at all times.
INVESTIGATION FINDINGS:
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This report supersedes report issued on 12/23/2019 following the receipt of additional information.

Licensing Program Analyst (LPA) Wolter arrived at the facility on 05/21/2021 to deliver complaint findings for allegation: Staff failed to ensure that resident had his oxygen tank at all times. LPA met with Executive Director (ED), Kayla Davis and explained the purpose of the visit.

Community Care Licensing (CCL) reopened the complaint on 07/20/2020 after receiving additional information. CCL conducted interviews and reviewed documentation relevant to the allegation: Staff failed to ensure that resident had his oxygen tank at all times. According to statements provided by witness (W1), the Health Service Director (S1) guaranteed that the resident (R1) would be checked on by a facility caregiver every 2 hours to ensure R1 was using oxygen as ordered.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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 5
Control Number 27-AS-20191105095006
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: 05/21/2021
NARRATIVE
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Facility notes reviewed did not indicate that R1 was checked on every two hours as agreed upon with the facility. Additionally, there was no plan of care indicating that R1 could not put their oxygen on their own and needed to be frequently checked to make sure that they were connected to their oxygen concentrator. Furthermore, according to hospital records, R1 had a tendency to remove their nasal cannula and be not connected to oxygen concentrator due to confusion brought on by hypoxia secondary to R1’s diagnosis of COPD. (Hypoxia is a dangerous condition that occurs when the human body doesn't get enough oxygen. - www.mayoclinic.org). The staff failed to ensure that the resident was connected to their oxygen concentrator at all times by not checking the resident on a frequent basis the previous evening and during the night. There was no facility documentation that the caregivers were checking on the resident on a frequent basis following R1’s arrival to the facility.

Based on information gathered, CCL finds the 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.

The following deficiency is cited on attached LIC 9099-D:
§1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
Definition is as follows:
[§1569.2 Definitions As used in this chapter:
(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.]

Exit interview conducted. Copy of report and appeal rights left with ED.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20191105095006
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2021
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
This requirement was not met as evidenced by: interviews and document review.
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The licensee is to review section 1569.312 and send a letter of understanding by 05/24/2021. Additionally, licensee will create and implement a plan to ensure residents are checked on regularly and that checks are documented. A copy of the plan is to be sent to CCL 05/24/2021.
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The licensee failed to comply with the regulation referenced above. Interviews and documentation reviewed revealed that R1 was not provided care and supervision to ensure their health and safety while in care of the facility. This poses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/05/2019 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20191105095006

FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:BRIGITTE LOESCHFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 57DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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This report supersedes report issued on 12/23/2019 following the receipt of additional information.

Licensing Program Analyst (LPA) Wolter arrived at the facility on 05/21/2021 to deliver complaint findings for allegation: Questionable Death. LPA met with Executive Director (ED), Kayla Davis and explained the purpose of the visit.

Community Care Licensing (CCL) reopened the complaint on 07/20/2020 after receiving additional information. CCL conducted interviews and reviewed documentation relevant to the allegation: Questionable Death. Interviews conducted and documentation reviewed revealed that the facility failed to ensure that the resident (R1) had access to their oxygen tank at all times as ordered.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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 5
Control Number 27-AS-20191105095006
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: 05/21/2021
NARRATIVE
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R1 moved into the facility on 10/22/2019 under hospice care and in stable condition, on the morning of 10/23/2019 the resident was found in their room without their oxygen cannula naked and on the floor. R1 was assisted into a chair and given their oxygen cannula, however staff noticed that R1 suddenly felt heavy. R1’s vital signs were taken, and hospice nurse was notified, by the time hospice nurse arrived to the facility R1 had expired.

Based on information gathered, CCL finds the allegation to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5