347001970-12-23-2021-27-AS-SRIN-CABVNK-20220103153517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001970
Report Date: 12/23/2021
Date Signed: 12/23/2021 01:50:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210920112902

FACILITY NAME:	WATERLEAF AT LAND PARK, THE		FACILITY NUMBER:	347001970
ADMINISTRATOR:	CIMINO, PAUL		FACILITY TYPE:	740
ADDRESS:	966 43RD AVENUE		TELEPHONE:	(916) 394-9400
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	78	CENSUS: 47	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Coreen Tigley		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained an injury while in care
Resident sustained multiple falls while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Victoria Brown and Jamie Ivey Canady arrived unannounced to conclude the investigation of the above mentioned allegations on 12/23/21 at 9:00am.

LPAs was met by Coreen Tigley and stated the purpose of the visit.

LPA requested and reviewed the following documents regarding resident #1 (R1): Hospital After Visit Summary, Facility Narrative Charting by staff and physcian, Physician report, Updated Physcian's Orders on medications, Admission Agreement, door documentation and survellance footage of the incident, Incident reports for R1 of falls for 2021. LPAs interviewed residents and staff during this visit.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

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 27-AS-20210920112902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WATERLEAF AT LAND PARK, THE	FACILITY NUMBER: 347001970
	VISIT DATE: 12/23/2021

NARRATIVE

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Regarding allegation, “Resident sustained an injury while in care”, LPA conducted interviews of the staff and the Physician of R1, the Principal Inspector for Commercial Buildings, representative for Allegion (LCN), Code Enforcement and reviewed the video of the incident in which Resident #1 (R1) was involved in on 9/8/2021.

LPA observed that R1 was visiting the Assisted living side of the building and was coming through the door. While talking to other residents, R1 did not remove hand from the door jamb of the door as it was closing. In speaking with a representative of Allegion (LCN), it was stated that “ low energy models, sensors are not required, and the closing force is 9lbs from the hinge edge which means 9lbs of force to be placed to counteract the door”. The investigation revealed that although R1 sustained an injury while in care the facility was deemed to not be at fault.

Regarding allegation, “Resident sustained multiple falls while in care” LPA observed medical documentation that R1 was seen at the hospital for a fall on two occasions that was not witnessed. The dates were 5/11/21 where a contusion of the head occurred and 8/21/21 where there was a laceration repair.
A review of the most recent physician report does not indicate that R1 is a fall risk. R1 ambulates without assistance of any device on a daily basis.

The preponderance of evidence standards has not been met. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

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