347001970-2-21-2023-27-AS-KHOS-CPFMSC-20230227085141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001970
Report Date: 12/01/2022
Date Signed: 02/21/2023 03:36:58 PM

Unsubstantiated

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
11/02/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20221102103332

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: 55	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Coreen Tigley		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff are administering resident's insulin

INVESTIGATION FINDINGS:

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AMENDED FROM UNFOUNDED TO UNSUBSTANTIATED
Upon further review of documentation and interviews the finding is changed. Administrator agrees. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 12/1/22 at 12:15pm. LPA met with Coreen Tigley and stated the purpose of the visit. LPA received a resident and staff roster with contact information durng this visit. LPA conducted interviews of residents (R1- R4) and staff (S1-S16). Based on interviews conducted today with staff and residents, who concur that staff are assisting residents with self administration of insulin and blood sugar level checks using the hand over hand method. LPA observed there is 1 resident who does not have the Libre machine attached to their skin. That resident stated that the blood sugar checks and insulin injection is self administered using the pre-filled pen as prescribed by the physician. The preponderance of evidence standards has not been met. Per the California Code of Regulations, Title 22, Div 6, Ch 8, no violations cited during this visit. Exit interview conducted copy given.

Unsubstantiated

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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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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