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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001970
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:21:08 PM

Substantiated


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
09/30/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240930213240
FACILITY NAME:WATERLEAF AT LAND PARK, THEFACILITY NUMBER:
347001970
ADMINISTRATOR:COREEN TIGLEYFACILITY TYPE:
740
ADDRESS:966 43RD AVENUETELEPHONE:
(916) 394-9400
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:78CENSUS: DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Coreen TigleyTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff yelled at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the The Waterleaf at Land Park RCFE on 11/6/24 at 11:05am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Coreen Tigley and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA conducted and interview with S1 and S2 who confirmed the allegation, although staff may not have raised their voice to resident, a comment was made about getting the staff member in trouble to R1 which is determined to be a violation of R1's personal rights.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 5
Control Number 27-AS-20240930213240
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: WATERLEAF AT LAND PARK, THE
FACILITY NUMBER: 347001970
VISIT DATE: 11/06/2024
NARRATIVE
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The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240930213240
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: WATERLEAF AT LAND PARK, THE
FACILITY NUMBER: 347001970
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by statements confirming S1 made a comment to resident about getting her in trouble which poses a
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Facility will submit training for personal rights for the identified staff by the POC due date.
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potential health, safety or personal rights risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/30/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240930213240

FACILITY NAME:WATERLEAF AT LAND PARK, THEFACILITY NUMBER:
347001970
ADMINISTRATOR:COREEN TIGLEYFACILITY TYPE:
740
ADDRESS:966 43RD AVENUETELEPHONE:
(916) 394-9400
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:78CENSUS: 50DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Coreen TigleyTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Personal Rights: Staff Hit Resident
Physical Plant: Staff did not provide a safe and comfortable environment for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the The Waterleaf at Land Park RCFE on 11/6/24 at 11:05am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Coreen Tigley and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted interviews with four staff members and four residents. All four staff interviewed denied ever witnessing any staff member hit a resident. Three of the four residents interviewed also denied ever being hit by a staff member or being treated disrespectfully by facility staff.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 5
Control Number 27-AS-20240930213240
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: WATERLEAF AT LAND PARK, THE
FACILITY NUMBER: 347001970
VISIT DATE: 11/06/2024
NARRATIVE
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LPA interviewed the alleged victim and could not obtain accurate information from R1 as their medical diagnosis and language barriers made it difficult to obtain information. LPA was able to have a translator who spoke a language identified to LPA and the translator had difficulty translating as they changed from several languages mid sentence and translator could not provide an accurate account of R1's statements to LPA. The RP and A1 interviewed were not present for the alleged incident.

LPA inspected the facility and conducted a walk through of the facility and observed R1's bedroom which met all title 22 requirements. LPA obtained no evidence to support the allegations of physical plant.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights and physical plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5