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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700202
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:56:59 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
08/03/2020 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200803144309
FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:MELISA TIBURCIOFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 100DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kayla DavisTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Unqualified staff administrating medication to residents
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Monday July 12, 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 reviewed S1's training records and interviewed relevant staff. LPA learned that one caregiver was tasked with handing out medication without proper training. As a result of this investigation, the Department 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
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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
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
08/03/2020 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200803144309

FACILITY NAME:VILLAGE AT HERITAGE PARK, THEFACILITY NUMBER:
342700202
ADMINISTRATOR:MELISA TIBURCIOFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 100DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kayla DavisTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Medical logs are not being filled out
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Monday July 12, 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 reviewed resident eMars and interviewed relevant staff. LPA could not find evidence that medical logs were being not being filled out appropriately. Therefore, the Department finds the allegation to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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 27-AS-20200803144309
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: 07/12/2021
NARRATIVE
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means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Appeal rights and a copy of this report was left with Administrator Kayla.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20200803144309
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: 07/12/2021
NARRATIVE
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 met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights and a copy of this report was given to Administrator Kayla.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200803144309
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: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited
CCR
87411(D)(4)
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Personnel Requirements-general
(d) All personnel shall be given on the job training . . . as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications . . This
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Facility will schedule training with all care staff (caregivers, med techs, and nurses) regarding proper medication distribution per facility's protocol and regulations.
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requirement was not met as evidenced by staff acknowledging they passed out medications as a caregiver. This is a direct threat to the health and safety of 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5