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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700525
Report Date: 08/17/2023
Date Signed: 08/23/2023 10:37:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230510111939
FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 113DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Stephen MacdonaldTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained injury, fracture to spine, as a result of a fall.
Facility is not meeting resident's needs.
INVESTIGATION FINDINGS:
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***This report is amended to amend the plan of correction***

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/17/23 to deliver complaint findings for above allegations. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened by facility staff upon entry.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 59-AS-20230510111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 08/17/2023
NARRATIVE
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Allegation: Resident sustained injury, fracture to spine, as a result of a fall: Substantiated

The department conducted a records review, staff and residents’ interviews to investigate this allegation. From record review, it has been observed that R1 fell in the bathroom while S1 was assisting them on 02/14/23. Facility sent out R1 to the hospital to get medical care after the fall incident where R1 was diagnosed with a fractured neck which required surgery to fuse the C1 and C2 vertebrae. During hospital stay, R1 health declined and was placed on hospice care in March 2023. From resident’s interviews, it has been concluded that R1 sustained a fall on 02/14/23 due to staff’s (S1) lack of supervision and care. Facility management received complaints regarding S1’s work ethic, including S1s disappearance during their working shifts. During a department interview with S1 regarding the fall R1 sustained on 02/14/23, S1 did not provide clear answers on what happened at the time of R1’s fall.

During the staff’s interviews, the department interviewed S4 who worked with S1 on 02/14/23. S4 stated that there was a lot of miscommunications that occurred during the shift. S4 stated that they were on their lunch break and heard the radio go off at least eight (8) different times during their 30-minute lunch break to assist R1 back to her room. S4 was called to assist after the fall had occurred with R1 and stated that S4 believed the fall happened due to an improper transfer because of the way R1 was laying on the floor.

During staff interviews, S1 stated that they were frustrated and overwhelmed the night R1 fell (02/14/23). S1 stated that they had been working a double shift. S1 acknowledged that R1 was left in a hallway unattended for at least 40 minutes before S1 arrived to assist. S1 admitted that S1 had never worked with R1 before 02/14/23 and was unfamiliar with R1’s needs. S1 assisted R1 back to their room and R1 in their wheelchair. S1 answered the radio and retrieved some items she had dropped. During this time, S1 observed R1 turn their wheelchair and move towards the restroom for approximately 30 seconds before R1 fell.

Based on review of R1’s facility assessment and needs and service plan which was conducted on 02/01/23, R1 required 1-person total assistance with toileting and transferring. Additionally, R1 was noted as a fall risk and required supervision to reduce the risk of falls.

Based on this information, the allegation’ Resident sustained injury, fracture to spine, as a result of a fall’ is found to be Substantiated.

**continued on 9099C.....

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230510111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 08/17/2023
NARRATIVE
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Allegation- Facility is not meeting resident's needs. -SUBSTANTIATED.

The department conducted a records review, staff and residents’ interviews to investigate this allegation. From record review, it has been observed that on 02/14/23, R1 fell in the bathroom while S1 was assisting R1 to the bathroom. Facility sent out R1 to the hospital to get medical care after this fall incident at which time R1 was diagnosed with a fractured neck which required surgery to fuse the C1 and C2 vertebrae together. During hospital stay, R1’s health declined and R1 was placed on hospice care in March 2023. From residents’ interviews, it has been concluded that R1’s fall on 02/14/23 was due to staff’s (S1) lack of supervision and care. R1 moved to the facility on 02/01/23 and based on R1’s facility assessment and needs and service plan, R1 required 1-person total assistance with toileting and transferring. Additionally, R1 was noted as a fall risk and required supervision to reduce the risk of falls. Record review and interviews indicated that facility did not provide proper care and supervision which resulted R1’s sustaining a fall on 02/14/23 causing serious bodily injury to R1. The allegation’ Facility is not meeting resident’s needs’ is found 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 met. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. 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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20230510111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/18/2023
Section Cited
CCR
87464(f)(1)
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87464-Basic Services-(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not as evidence by….
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Licensee agrees to the following:
Licensee will make sure to provide care and supervision to residents so residents care needs can be met per RCFE regulation 87464. Licensee shall submit letter of understanding of this regulation and staff training to CCL by POC date-08/18/23.
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Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 in which R1 sustained a fall on 02/14/2023 resulting in a fractured neck which poses an immediate health and safety risk for residents in care.
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Additionally, the facility will conduct monthly staff training to mitigate falls and injuries for residents and send weekly training records to CCL for next 90 days. Additionally, the facility will submit a plan on how the licensee will ensure staff are aware of all resident care needs.
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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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20230510111939

FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 113DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Stephen MacdonaldTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not ensure that activites are available for residents.
Facility did not ensure that resident's room maintained cleanliness.
Facility not allowing resident to eat in the dining room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/17/23 to deliver complaint findings for above allegations. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened by facility staff upon entry.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230510111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 08/17/2023
NARRATIVE
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Allegation- Facility did not ensure that activities are available for residents- UNFOUNDED.

The department conducted a record review, facility observations and staff and resident’s interviews to investigate this allegation. Interviews conducted with staff indicated that there is always a facility staff person in the memory care unit to do activities with residents. LPA observed multiple facility staff to be present during exercise class on 08/08/23 in the morning time during facility’s tour and observed that 20-25 residents were present in that activity session in memory care unit. LPA observed a large monthly activities calendar posted as well as a daily hour schedule of activities in the communal of the memory care unit. Records review and interviews found that the licensee employs a full-time activities coordinator for the assisted living and for memory care unit. Specific to residents in memory care, activities are available and utilized when or if residents can participate. Residents’ interviews indicated that the facility was providing meaningful activities daily to residents and did not express any concerns. Based on information obtained, LPA finds the above allegation to be UNFOUNDED.

Allegation-Facility did not ensure that resident's room maintained cleanliness. - UNFOUNDED

LPA investigated the allegation, "Facility did not ensure that resident's room maintained cleanliness ". On 08/08/23, LPA conducted a facility tour which included residents’ rooms, medication room, and common living spaces in the memory care unit and assisted living areas of the facility. LPA observed that the facility was clean, safe and sanitary and odor free. LPA interviewed staff, and all staff who stated the housekeepers keep the facility clean and are cleaning daily. LPA interviewed residents in care in which they stated the facility was always clean. Due to the information gathered, LPA finds the allegation to be UNFOUNDED.

Allegation- Facility not allowing resident to eat in the dining room. - UNFOUNDED

The department conducted staff and residents' interviews, reviewed records and facility observations to investigate the allegation. During residents interviews, it has been found out that residents can request meal tray service to their rooms if they do not want to eat in dining room. Residents stated that there have been no issues with tray delivery service to their rooms and they can choose where they want to eat. Staff interviews indicated that they were not aware of any issues with residents’ meal services. During the department visit on 08/08/23, LPA observed residents were enjoying their breakfast in their rooms and in the dining area. Based on the information, this allegation is found to be UNFOUNDED.

A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6