342700821-10-6-2021-25-AS-MSEY-C7KPEJ-20211007111513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700821
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:19:09 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
06/23/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210623104810

FACILITY NAME:	BLUEBERRY HILL SENIOR LIVING, INC.		FACILITY NUMBER:	342700821
ADMINISTRATOR:	HAMRIC, KEITH		FACILITY TYPE:	740
ADDRESS:	3827 OLIVE LANE		TELEPHONE:	(916) 900-8399
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Victoria Zedan, caregiver		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility not allowing resident to have visitors
Facility staff verbally abusive towards resident
Facility is not following resident's care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint the department received on 6/23/2021. LPA discussed complaint findings with Administrator, Keith Hamric, by phone, who was not able to be at the facility at the time of the inspection. Caregiver confirmed there are (6) residents present and there are currently no residents receiving hospice services. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the course of the investigation, LPA interviewed Administrator, (1) staff, (3) residents, Ombudsman, resident's (R1) representative and family member. LPA reviewed documentation pertaining to resident, including, but not limited to, physician's report, appraisal, care plan and a letter from another resident's representative. The results of the investigation are as follows:

Allegation: Facility not allowing resident to have visitors:

Interview with (2) residents revealed they have had family visitors on a regular basis and there have been no situations where visitation has been denied, with one resident stating her family will inform the facility in advance prior to visiting. Resident (R1) stated the facility does allow her to have visitation with her family

cont on 9099-C.(1) ...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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 25-AS-20210623104810

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: BLUEBERRY HILL SENIOR LIVING, INC.	FACILITY NUMBER: 342700821
	VISIT DATE: 10/06/2021

NARRATIVE

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9099-C (1) since she and her family have been vaccinated and that another family member was also allowed to visit with her inside the facility. Resident’s (R1) representative stated that resident is not able to leave the facility unattended due to having a diagnosis of early stages of Dementia and been hospitalized in the past due to certain behaviors. Resident’s representative confirmed there are not any restraining orders in place currently. Resident’s (R1) physician’s report, dated 10/15/2020, states that she has a diagnosis of Cerebrovascular Disease and Mild Cognitive Impairment and is confused at times. Skilled Nursing facility notes, dated 10/29/2020, states resident (R1) has Dementia and will be going to assisted living. Care plans, dated 3/24/2021, indicate that resident has a diagnosis of Dementia and is at risk for wandering.

Staff (S1) interviewed stated she is not aware of any issues with visitation. Administrator stated that he “appreciates advance notice” and schedules visiting in advance, staying within the facility’s visiting hours, due to Covid -19 precautionary measures. Administrator stated that he had spoken by phone with resident’s (R1) family member regarding visitation on/around 6/14/2021, and requested she provide him with advance notice in scheduling visitation to minimize the cross traffic at any given time at the facility, per Covid-19 precautionary measures. Administrator stated he did not tell resident's (R1) family member by phone she couldn't visit and did not refer her to resident's POA for approval prior to visiting. Additionally, Administrator stated there was never a discussion with resident's family member about taking resident (R1) off site for visitation. Administrator stated that when resident’s family member arrived at the facility on 6/19/2021, resident (R1) ran to the front door, without her walker and darted outside and almost fell. Administrator stated that resident’s family member was allowed to visit inside the facility with resident (R1) on 6/19/2021, as resident has dementia, is a fall-risk and often needs reminders to use her walker to ensure her safety.

Resident’s (R1) family member stated resident heard her voice when she came to the door and the Administrator allowed them to have a visit inside. Resident’s family member stated that the Administrator told her he was “okay” with her visiting when they spoke on the phone, and she has been fully vaccinated so could not have been denied inside visitation.

Letter provided from a resident’s representative states that the Administrator is “diligent about following all of the required licensing rules and Covid-related rules” and keeps families aware of visiting protocols to ensure the safety of the residents first.

cont on 9099-C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20210623104810

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: BLUEBERRY HILL SENIOR LIVING, INC.	FACILITY NUMBER: 342700821
	VISIT DATE: 10/06/2021

NARRATIVE

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9099-C(2)....PIN 21-17.2 issued 5/14/2021 states, in part, that “Licensees should allow indoor visitation, including in-room visitation, at all times and for all residents…” when Covid-19 precautionary measures are followed, and that “At all times when visitation is restricted under this waiver, licensees must allow for scheduled outdoor visits…” when Covid-19 precautionary measures are followed. Administrator stated he had reiterated to resident’s family member twice to call ahead of time for visitation on/around 6/14/2021 when they spoke by phone. LPA observed visiting hours to be posted by the visitor sign-in log at the facility entrance.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Facility staff verbally abusive towards resident.

Interview with (2) residents indicated that all staff is very caring, listens well to resident’s concerns, is always kind and professional and does not yell, but sometimes may have to raise their voice slightly, or speak sternly, to get a resident’s attention. Resident (R1) stated that she enjoys living at the facility and staff does not yell at anyone. Resident’s (R1) representative stated that he has not observed any staff to be verbally abusive to resident (R1) when he visited.

Staff (S1) interviewed stated she has never yelled at a resident or observed other staff to do so. Administrator stated he has never been verbally abusive or asked any inappropriate questions to any residents or staff.
Letter from another resident’s family member states that the Administrator does not raise his voice at residents, even if a resident can be challenging and doesn’t want to initially follow safety protocols. The letter continues to state that Administrator will calmly, but firmly, speak to residents about following safety guidelines.

Ombudsman stated he spoke with resident’s (R1) representative who indicated that resident(R1) has never told him that facility staff have been rude or disrespectful or said anything inappropriate to resident (R1) at any time. Additionally, Ombudsman indicated that resident (R1) told him that she enjoys living at the facility and all staff have been respectful to her.
cont on 9099-C (3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20210623104810

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: BLUEBERRY HILL SENIOR LIVING, INC.	FACILITY NUMBER: 342700821
	VISIT DATE: 10/06/2021

NARRATIVE

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9099-C(3)...Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Facility is not following resident's care plan

One resident interviewed stated that she receives help with medications and shower reminders. Another resident interviewed stated that staff is “very helpful and meet my needs” and staff does not yell but possibly talks loudly and she is receiving the assistance she needs with showering, toileting and medications.
Resident (R1) stated she receives assistance with her hair, making her bed, showers and medications. Care plan notes that resident (R1) does not need help with food or nourishment but receives assistance with bathing and needs a walker to get around safely due to her fall history and wandering tendencies. Resident’s (R1) updated care plan, dated 3/24/2021, from resident’s home health care, indicates that resident has Dementia or cognitive impairment and is at risk for wandering and uses a walker.

Staff (S1) interviewed stated she reviews each resident’s care plan to know if a resident has mild dementia or mild cognitive impairment and for medication information. Staff confirmed that the facility has an awake night staff. When asked if the facility is following resident’s (R1) care plan, Administrator stated that resident is a fall risk, requires a chaperone to the bathroom, assistance with showering, is independent with dressing and is "stand by" with brushing her teeth.

Letter provided from another resident’s representative states that the facility has provided “excellent care” to all residents and has closely monitored and cared for her family member whose health quickly improved after moving to the facility.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit Interview conducted.

There are no deficiencies cited from this report and allegations are being dismissed.
Exit interviewed conducted with caregiver, Victoria, who is authorized by Administrator to sign today's reports. Copy of report left at facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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