342700525-8-19-2022-25-AS-APEZ-CHVMJP-20220902093927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700525
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:53:10 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
03/30/2022 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220330143305

FACILITY NAME:	ALMOND HEIGHTS		FACILITY NUMBER:	342700525
ADMINISTRATOR:	AGUIAR, TERRI		FACILITY TYPE:	740
ADDRESS:	8685 GREENBACK LN		TELEPHONE:	(916) 542-7988
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	145	CENSUS: 91	DATE:	08/19/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Stephen Macdonald, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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9

Reporting requirements

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 08/19/2022 to deliver complaint findings for the allegation listed above, LPA met with Stephen Macdonald, Executive Director, and explained the purpose of the visit. Prior to initiating visit LPA completed daily self-screening questionnaire to confirm no symptoms of COVID-19 and wore surgical mask.

Through document review and staff interviews, it is determined that although facility may have generated SIR in house, it was never delivered to CCL, as required by regulations.

The department finds the allegation to be SUBSTANTIATED, a finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Exit interview conducted, appeal rights provided, and copy of report provided to facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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 25-AS-20220330143305

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: ALMOND HEIGHTS	FACILITY NUMBER: 342700525
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [...] (D) Any incident which threatens the welfare, safety or health of any resident [...]	1 2 3 4 5 6 7	Licensee to review section 87211 Reporting Requirements and send a letter of understanding to Community Care Licensing by 09/02/2022 by fax. Additionally, licensee to ensure incident reports are completely filled out and faxed to CCL.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: interviews and documentation reviewed. The licensee did not comply with the section cited above by not reporting incidents which threatened the welfare of R1. This poses a potential health, safety, and/or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
03/30/2022 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220330143305

FACILITY NAME:	ALMOND HEIGHTS		FACILITY NUMBER:	342700525
ADMINISTRATOR:	AGUIAR, TERRI		FACILITY TYPE:	740
ADDRESS:	8685 GREENBACK LN		TELEPHONE:	(916) 542-7988
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	145	CENSUS: 91	DATE:	08/19/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Stephen Macdonald, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff gave a resident alcohol who was not suppose to have alcohol which resulted in resident sustaining a fall.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 08/19/2022 to deliver complaint findings for the allegation listed above, LPA met with Stephen Macdonald, Executive Director, and explained the purpose of the visit. Prior to initiating visit LPA completed daily self-screening questionnaire to confirm no symptoms of COVID-19 and wore surgical mask.

The department conducted interviews and document review and it has been determined that the resident died of heart attack, not due to a fall or alcohol induced accident. Because the resident has passed away and the department cannot confirm if he was given alcohol, this allegation is determined to be UNSUBSTANTIATED.
A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of this report was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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 3