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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 09/27/2022
Date Signed: 10/31/2022 03:10:47 PM

Substantiated


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
05/05/2022 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220505130333
FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 59DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Questionable death.
Staff unaware of resident's whereabouts.
Resident's care needs were not met.
INVESTIGATION FINDINGS:
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THIS REPORT HAS BEEN AMENDED
On September 27, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint 25-AS-20220505130333. LPA met with Executive Director Kayla Davis and informed her the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a N-95 mask was worn for Personal Protective Equipment.

On 05/17/2022, the department received a complaint regarding the death of resident (R1). The incident occurred on 05/28/2021. On 05/24/2022, R1 an signed admission agreement on with the facility and moved into the facility on 05/26/2021. Interviews with Administrator indicated she was aware that R1 was moving into the facility however acknowledged that care staff were not aware of R1’s move in. A review of R1’s needs and service plan indicated R1 was at risk for falls and staff will monitor.
To continue see 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
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 6
Control Number 25-AS-20220505130333
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: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/28/2022
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities-(a) In addition to the rights listed its in All Facilities, residents in privately operated residential care facilities... the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The facility shall write a new policy on how staff are informed of new admissions including on weekends. This new policy shall be submitted to LPA no later than October 27, 2022.
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This requirement is not met as evidenced by: Facility staff did not follow R1's needs and service plan which documented R1 was a fall risk and required monitoring. R1 sustained a fall sometime on 05/27/2021 and was found on 05/28/2021 by R1's responsible party which posses an immediate health and safety risk to residents in care.
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Request Denied
Type B
09/28/2022
Section Cited
CCR
87405(d)(4)
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Administrator - Qualifications and Duties
(d) The administrator shall have qualifications specified in Sections 87405(d)(1) through (7). When applicable, the ability to direct the work of others. This requirement is not met as evidenced by:
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The licensee shall submit a list of Administrator duties which shall include how the Administror will notify staff in regards to new admissions.
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The Administrator did not ensure facility staff were aware of R1's move in to the facility which resulted in lack of monitoring and the delay of R1 receiving care after a unwitnessed fall which posses a potential health and safety risk to resident's 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: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20220505130333
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: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/28/2022
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in
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The licensee shall submit a plan on how staff will ensure that emergency services are sought timely for residents as required.
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Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Facility did not seek emergency services timely after R1 sustained an fall resulting in R1 sustaining a Bilateral subdural hematomas and forehead laceration which posses an immediate health and safety risk to resident's 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: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20220505130333
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: 09/27/2022
NARRATIVE
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 A review of R1's LIC602 Physicians report dated 05/19/2021 documented R1's medical diagnosis’ as history of prostate cancer, HTN, Hypothyroidism and Mild Cognitive Impairment. R1 was documented as ambulatory however used a cane for mobility assistance.

On 05/28/2021, R1's responsible party (RP) visited the facility to see R1. RP went to R1's room and upon entering R1's room, RP observed R1's door was unlocked. When RP entered the room, RP found blood on the floor and the bedroom door was closed. RP entered the bedroom and found R1 laying on the floor between the bedroom and bathroom.

RP believes that R1 fell in the kitchenette area before making their way to the bedroom and bathroom. There was blood on R1's bed. R1 was only wearing a blood soaked undershirt and underwear and had defecated on himself. The RP indicated that R1 had to have been on the floor for at least 12 hours. RP asked R1 what happened and stated that he had fallen sometime on Thursday (05/27/2021).

Interviews with staff indicated vacant rooms of the facility are not checked and that because staff were not aware R1 had moved into the facility, they did not check the room R1 moved in to. Interviews further disclosed that there have been several incidents of miscommunication between executive staff and care staff in regard to new move ins at the facility.

On 05/28/2021, 9-1-1 was called. EMT records indicated they found R1 lying on the ground. Patient seems to be in mild distress. R1 was observed to have an inch laceration that was not bleeding on forehead. R1 was also observed to have bruising to right eye.

Upon admittance to the hospital on 05/28/2021, R1 was diagnosed with Bilateral subdural hematomas, forehead laceration and put on comfort care.

R1 passed away on 06/01/2021. Death Certificate indicated R1's causes of death as cardiopulmonary arrest while on comfort care and traumatic subdural hematoma.

To continue see 9099-C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20220505130333
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: 09/27/2022
NARRATIVE
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Based on investigation, the facility failed to ensure that staff were aware that R1 moved into the facility. R1's needs and service plan indicated R1 was a fall risk which required staff to monitor. As a result of staff not meeting R1's needs, R1 sustained a fall in which timely medical assistance was not sought. As a result, R1 died as a result of the injuries.

In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care.

Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

The citation issued today is under review and a future civil penalty may apply based on 1569.49(f) H&S.

Failure to correct the deficiencies may also result in civil penalties.

Exit interview conducted. Appeal Rights provided. A copy of the report issued.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
05/05/2022 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220505130333

FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Allegation:
Staff provided false reports to licensing.


INVESTIGATION FINDINGS:
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THIS REPORT IS AMENDED
On September 27, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint 25-AS-20220505130333. LPA met with Executive Director Kayla Davis and informed her the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a N-95 mask was worn for Personal Protective Equipment

The Department conducted a review of incident reports submitted by the facility as well as interview conducted. It has been determined that facility staff have not made or provided false information on incident’s reports to the Department.
Based on the information obtained during the complaint investigation, The allegation is UNFOUNDED meaning false, could not have happened, and/or is without a reasonable basis
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6