342700202-7-9-2021-27-AS-LMUZ-C4UNUP-20210712104641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 07/09/2021
Date Signed: 07/09/2021 02:09:54 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
08/24/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200824113654

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	MELISA TIBURCIO		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS: 100	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Kayla Davis		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff not providing assistance to resident in a timely manner
Staff mishandling residents medication
Staff not providing adequate food service
Staff are not properly trained to use facility equipment

INVESTIGATION FINDINGS:

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LPA Lusby arrived on Friday July 9, 2021 to conclude a complaint investigation regarding the above allegation. Prior to 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA was screened by the front desk prior to entry.

Throughout the course of the investigation, LPA Lusby audited the medication room, reviewed resident files and medication administration records (MARs), interviewed staff, and interviewed residents. LPA Lusby was unable to find disrepencies in MARs reviewed. Staff and residents interviewed acknowledged that they received their food while it was warm. Residents and staff interviewed both acknowledged that resident's pendants are

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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 27-AS-20200824113654

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: 07/09/2021

NARRATIVE

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answered in a timely manner. Additionally, staff acknowledged that they are trained how to properly use the emergency evacuation chair upon hire and in subsequent all-staff training.

The Department finds the allegations to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. A copy this report was left at the facility. Appeal rights were given.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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