455001248-2-17-2021-25-AS-RLBN-BYPUC8-20210301142728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455001248
Report Date: 02/17/2021
Date Signed: 02/17/2021 03:13:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Misty Valencia

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20201210120357

FACILITY NAME:	WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.		FACILITY NUMBER:	455001248
ADMINISTRATOR:	BARNEY, ZYANYA		FACILITY TYPE:	740
ADDRESS:	191 CHURN CREEK ROAD		TELEPHONE:	(530) 242-0654
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	56	CENSUS: 43	DATE:	02/17/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Trish Clark, Health Services Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility Staff violated resident's personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA's) Misty Valencia conducted an unannounced complaint phone call and spoke with Trish Clark, Health Services Director. LPA explained the phone call was to deliver findings regarding the Facility Staff violated resident's personal rights allegation.

LPA’s finding for the Facility Staff violated resident's personal rights allegation -UNSUBSTATIATED.

continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

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 25-AS-20201210120357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.	FACILITY NUMBER: 455001248
	VISIT DATE: 02/17/2021

NARRATIVE

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The visit was to discuss an incident which occurred on 12/10/20, where S1 allegedly put a pillow over R1’s face during a behavior issue incident. R1 was not hurt or had any visible marks, but Administrator investigated the incident and found S1 guilty. S1 confessed to hugging R1 due to his behavior issue through a text message, but not putting a pillow over R1’s face. Administrator decided that even though R1 was not hurt or had any visual marks, S1 will be terminated. Administrator terminated S1, notified Adult Protective Services (APS) Community Care licensing (CCL) and filed a police report with Redding Police Department (RPD). Based on 8/10 staff interviews who all report that they have never witnessed any staff members abuse any of the residents, S1 who reports that she has never put a pillow over R1's face and records review, LPA determined that Facility Staff did not violate resident's personal rights.

The preponderance of evidence standard has not been met. The allegation is Un-Substantiated.

Based on the interviews and evidence obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited during today’s visit.

An exit interview was conducted with Trish Clark, Health Services Director, via telephone and a copy of this report, dated Feb 17, 2021 has been provided to via email and an electronic email read receipt confirms receiving this document

No further action required.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

LIC9099 (FAS) - (06/04)

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