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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701040
Report Date: 12/26/2023
Date Signed: 12/26/2023 01:52:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/05/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231105181914
FACILITY NAME:BRUCEVILLE POINTFACILITY NUMBER:
342701040
ADMINISTRATOR:HOSTETTER, ERICFACILITY TYPE:
740
ADDRESS:9730 BACKER RANCH ROADTELEPHONE:
(916) 226-5300
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:200CENSUS: 143DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Misty VelozTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident was left unattended without staff supervision resulting in hospital visit
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with designated staff person Misty Veloz, and explained the purpose of the visit.

The Department has determined the following as it relates the allegation of: Resident was left unattended without staff supervision resulting in hospital visit. The investigation consisted of interview with responsible parties, interview with facility staff, video recording review, and facility records review.

On 11/06/23, LPA Valerio conducted a 10-Day Visit after being informed that Resident 1 (R1) had fallen on a Friday night and was not found by staff until Sunday morning. R1 did not have the call pendent on one's self to call for help. On Sunday morning, R1 was found to be dehydrated and had not eating or taken medications. R1 was taken to the hospital right away.

Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
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 4
Control Number 27-AS-20231105181914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BRUCEVILLE POINT
FACILITY NUMBER: 342701040
VISIT DATE: 12/26/2023
NARRATIVE
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Continued from LIC 9099

According to an interview with a responsible party (RP), the responsible party stated the facility informed the RP of the incident and immediately assisted the resident. The RP stated the facility corrected the issue and made adjustments to the care plan to ensure the incident with R1 does not happen again.

LPA reviewed facility records. According to an incident report submitted by the facility on 09/27/23, R1 had an incident on 09/24/23. Housekeeping staff went to resident's apartment at 10:30 AM and R1 was found on the couch. R1 stated R1 did not feel well and housekeeping called for staff assistance. Resident told staff 3 (3) and staff 4 (S4) that R1 was having back pain and leg pain and had been on the couch since the night before (Saturday night). When Emergency Medical Support staff arrived R1 informed EMS staff that R1 has been on the couch since Friday Night. R1 was treated in the hospital for dehydration and impacted bowel. According to the incident report, Administrator Eric learned from R1's RP that R1 missed Saturday's AM/PM dose of medication.

LPA reviewed facility records for R1. According to R1's LIC 602 Physician Report, R1 is considered an independent adult. R1 does not require continued bed care, is able to bathe, dress/groom, feed, and care for own toileting needs, able to administer own prescription medications, and able to store own medications. According R1's Needs and Service Plan, night-time checks utilizing the manual "flipper" door monitoring system is adequate for resident's current needs. Both the LIC 602 and Needs and Service Plan are signed by the RP and Facility Administrator.

LPA interviewed staff. According to S1 and S2, R1 reported conflicting information as to when R1 had fallen. One moment R1 stated Saturday evening and the next moment it was reported Friday evening. S2 states that staff are good about checking on the resident's daily. S2 stated that the facility has implemented an extra step to the monitoring system by having staff initial stating they checked on each resident, even those who are considered independent. According to S3, S3 did not see R1 on Friday; however, did see R1's flipper down. S2 stated that the flipper down means that the resident opened their door that day.

LPA Valerio reviewed video footage recordings provided by the facility. The facility has security cameras located in common areas of the facility.
Continues on Page 3, LIC 9099 - C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20231105181914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BRUCEVILLE POINT
FACILITY NUMBER: 342701040
VISIT DATE: 12/26/2023
NARRATIVE
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Continued from Page 2, LIC 9099 - C

Video footage revealed that on 09/22/23 22:45:03 - NOC staff, Staff 4(S4), is seen walking down the hallway. S4 flips up the flipper, which indicates that the flipper was down. On 09/23/23 11:11 AM - AM staff, S3, is seen walking down the hallway. S3 is seen walking up and down the hallway. On 09/23/23 22:29:00 NOC staff, S4, is seen walking down the hallway. S4 is seen going to the door of the resident; however, the camera does not catch whether or not the staff member opened the door or the flip was switched. The staff was in front of the door for less than 10 seconds.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

An exit interview was held, and a copy of report was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/05/2023 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20231105181914

FACILITY NAME:BRUCEVILLE POINTFACILITY NUMBER:
342701040
ADMINISTRATOR:HOSTETTER, ERICFACILITY TYPE:
740
ADDRESS:9730 BACKER RANCH ROADTELEPHONE:
(916) 226-5300
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:200CENSUS: 142DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Misty VelozTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not report incident to Department
INVESTIGATION FINDINGS:
1
2
3
4
5
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10
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with designated staff person Misty Veloz, and explained the purpose of the visit.

The Department has determined the following as it relates the allegation of: Facility did not report incident to Department. The investigation consisted of interviews with staff, facility record reveiw, and Regional Office file review.

LPA reviewed the RO's facility files and did not observe an SIR submitted. However, according to an interview with S2, S2 stated Administrator Eric always submits them and submitted a copy for reference. The document shows that Administrator Eric Hostetter sent a EFAX via Ring Central to (916) 263-4744 on Wednesday, September 27, 2023 at 5:52 PM. Based on this information, the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiences are being cited. An exit interview was held, and a copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4