342700370-7-20-2021-27-AS-MSEY-C55KPS-20210721080511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700370
Report Date: 07/02/2021
Date Signed: 07/20/2021 11:23:06 AM

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
03/10/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20210310120101

FACILITY NAME:	PRAIRIE CITY LANDING		FACILITY NUMBER:	342700370
ADMINISTRATOR:	MARTIN, CHERYL K		FACILITY TYPE:	740
ADDRESS:	645 WILLARD DR		TELEPHONE:	(916) 458-0303
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	200	CENSUS: 128	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jan McLennon, Resident Service Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff assaulted a resident while in care

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED DOCUMENT - AMENDED ON 07/20/21
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to investigate allegations listed above. LPA met with Resident Service Director Jan McLennon upon time of arrival. 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, "Staff assaulted a resident while in care". LPA interviewed 5 staff members and 3 residents and conducted a file review. R1 reported a staff member had hurt them during the night. LPA interviewed R1 in which they stated they were hurt by a staff member, but could not give details of when and how it occurred. R1 informed LPA they do feel safe at the facility.
Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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-20210310120101

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: PRAIRIE CITY LANDING	FACILITY NUMBER: 342700370
	VISIT DATE: 07/02/2021

NARRATIVE

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THIS IS AN AMENDED DOCUMENT - AMENDED ON 07/20/21.
LPA interviewed 2 other residents in which they stated they felt safe at the facility and staff have not hurt them in any way. LPA interviewed 5 staff in which they stated they have not witnessed any staff hurting R1 or any other residents in care. Staff member stated R1 reported to them that a man had hurt them during the night. Staff reported incident to CCL, police department, ombudsman, responsible parties and physician. Administrator stated they reviewed video footage and no one was observed entering into R1's room. Staff reported resident can have hallucinations at times, and R1 has reported the same incident several times. LPA conducted a record review and R1's physician report records resident has a diagnosis of dementia. Facility continues to report incidents to all required parties, and has not found evidence that incident has occurred. Due to information gathered LPA finds allegation to UNFOUNDED.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

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