347005580-3-17-2023-59-AS-KHOS-CQDK3E-20230329073238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005580
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:53:50 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
03/08/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230308110622

FACILITY NAME:	MOUNTAIN MANOR SENIOR RESIDENCE		FACILITY NUMBER:	347005580
ADMINISTRATOR:	DARRELL PRICE		FACILITY TYPE:	740
ADDRESS:	6101 FAIR OAKS BLVD		TELEPHONE:	(916) 488-7211
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	33	CENSUS:	DATE:	03/17/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Darrell Price		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident caused injuries to another resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 3/17/2023 to open and deliver the findings of a complaint the Department received regarding the allegation cited above. LPA met with Administrator, Darrell Price and explained the purpose of the visit. LPA wore the following Personal Protective Equipment: surgical mask. Additionally, LPA was screened and tested at entrance by staff.

During today's visit, Administrator informed LPA the incident occurred at skilling nursing facility, not in the assist living unit. LPA informed Administartor CCLD does not regulate skilled nursing, it will be public health. Administrator stated public health was informed of the incident and has came out retrieve documents.

Based on the interview conducted, LPA found the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit Interview conducted and a copy of the report was left at the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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 3