342700525-5-29-2024-59-AS-LMUZ-D5RTH8-20240530144419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700525
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:03:02 AM

Unsubstantiated

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
04/04/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240404105609

FACILITY NAME:	ALMOND HEIGHTS		FACILITY NUMBER:	342700525
ADMINISTRATOR:	MACDONALD, STEPHEN		FACILITY TYPE:	740
ADDRESS:	8685 GREENBACK LN		TELEPHONE:	(916) 542-7988
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	145	CENSUS: 108	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Stephen Macdonald		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff do not respond to resident's call for assistance in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit.

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

**Report continued on LIC9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4

Control Number 59-AS-20240404105609

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: 05/29/2024

NARRATIVE

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***Report continued from 9099.......

Allegation- Staff do not respond to resident's call for assistance in a timely manner.-Unsubstantiated

The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents’ interviews indicated that staff were assisting with their care needs and responding to the call lights in timely way however there were some delay times if staff were assisting other residents. Staff interviews indicated that staff were trying their best to respond to resident’s call light in the best possible way and tried to prioritize their response per resident’s needs. Record review conducted for call light log March 2024 revealed some dates and times with extended response time without any definite reason. Although record review revealed there were some dates and time with long call response, California Code of Regulation, Title 22, does not specify a time frame of when facility is to assist to a non-emergency call. Additionally based on interviews with staff, it revealed that facility staff has the tendency to "forget to reset the system at the conclusion of the service they are doing". Therefore, the allegation cited above is Unsubstantiated.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
04/04/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240404105609

FACILITY NAME:	ALMOND HEIGHTS		FACILITY NUMBER:	342700525
ADMINISTRATOR:	MACDONALD, STEPHEN		FACILITY TYPE:	740
ADDRESS:	8685 GREENBACK LN		TELEPHONE:	(916) 542-7988
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	145	CENSUS: 108	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Stephen Macdonald		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff are caring for residents without adequate training.
Staff do not transfer residents that require 2 person assistance in a safe manner.
Staff do not rotate residents as required to prevent pressure injuries.
Untrained staff dispensing medications to residents.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4

Control Number 59-AS-20240404105609

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: 05/29/2024

NARRATIVE

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**Report continued from 9099-A.....
Allegation- Staff are caring for residents without adequate training. Staff do not transfer residents that require 2 person assistance in a safe manner. -Unfounded

The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that staff have adequate training (on boarding and ongoing) regarding residents safe transfers techniques and there were no issues. Staff interviews also reflected that they were feeling safe regarding any residents who required 2 persons assist with transfers. Six (6) residents interview indicated that staff were properly trained, and residents felt safe with staff’s care without any problems. Record review indicated that facility has all required documentation regarding staff’s training's regarding Residents Transfers Techniques and other Care Provision per Requirement, therefore these allegations were found to be Unfounded.

Allegation- Staff do not rotate residents as required to prevent pressure injuries.- Unfounded

The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents interview indicated that staff were providing care per their care needs and there were on issues including those residents who required staff to turn and reposition. Staff interviews revealed that staff were aware which residents needs turning and repositioning per their care needs and were providing that care and documenting it timely. Based on information gathered, this allegation was found to be Unfounded.

Allegation -Untrained staff dispensing medications to residents. -Unfounded

The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that facility has trained staff who were managing residents’ medications and has access to medication room. Staff interviews denied that any unauthorized person was dispensing residents’ medications. There were some staff who were cross trained to do other duties and those staff also fill-in to do Med Tech job as needed per facility’s staffing needs. Record review indicated that facility has proper documentation of resident’s medication administration and there were no discrepancies. Based on information gathered, this allegation was 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.No citations were issued. Exit interview conducted.A copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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