455001248-11-7-2023-59-AS-LCRR-CYBLVC-20231208080519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455001248
Report Date: 11/07/2023
Date Signed: 11/07/2023 09:25:07 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
08/22/2023 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20230822131304

FACILITY NAME:	WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.		FACILITY NUMBER:	455001248
ADMINISTRATOR:	GOSTAS, DARIEN		FACILITY TYPE:	740
ADDRESS:	191 CHURN CREEK ROAD		TELEPHONE:	(530) 242-0654
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	56	CENSUS: 46	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	PATRICIA CLARK		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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A staff person injured a resident.

INVESTIGATION FINDINGS:

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On 11/06/23 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/22/23. LPA Gurriere met with Patricia Clark, Administrator, and explained the purpose of the visit.

A staff person injured a resident.

During the interview process, the persons that were involved with the incident were interviewed. The resident (Resident 1) was not interviewed, as she has severe dementia, and it was reported that she does not remember the incident. Documents were received and reviewed to include the nursing evaluation of where the injuries were noted, Physician’s Report, Physician Progress Report, hospital records, Residence and Care Agreement, Employee Records, and skin tear photos.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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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Control Number 59-AS-20230822131304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.	FACILITY NUMBER: 455001248
	VISIT DATE: 11/07/2023

NARRATIVE

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continued

During the investigation, it was reported that a staff person was assisting a resident by getting her from her wheelchair to her bed when the resident became combative. It was stated that the staff person tried to put up her hands to block the resident from hitting her and placed her hands on the resident’s forearms and by doing so, caused skin tears and bruising. It was reported that the staff person noticed blood on the resident’s clothing and called for the facility nurse to come and assist. The nurse arrived and applied steri-strips to the resident’s arms; it was reported that the resident did not complain of any pain and soon thereafter went to sleep. The following day, the health care director contacted the physician, and he recommended that the resident be sent out to the hospital for further evaluation. It was stated that the resident did not remember the incident due to her dementia status.

It was reported that the staff person was terminated from her position, as she did not follow the protocol of the facility’s policy when a resident is being combative. It was stated that the staff should have called in another staff person to “trade out” staff persons when the resident became combative. Although it was stated that the staff person was remorseful and trained, the resident suffered serious skin tear injuries.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 59-AS-20230822131304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.	FACILITY NUMBER: 455001248
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/08/2023 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Care and supervision means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.	1 2 3 4 5 6 7	The administrator agrees to provide training to staff persons regarding the facility’s protocol of caring for a dementia resident when the resident becomes combative. Administrator shall submit names of staff persons trained and training material to the licensing agency by 11/08/23.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews of staff persons and records reviewed, the licensee did not ensure that the resident was protected from an injury.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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