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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002049
Report Date: 04/24/2023
Date Signed: 04/24/2023 10:19:47 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, 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
03/29/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230329135015
FACILITY NAME:VISTAS ASSISTED LIVING & MEMORY CARE, THEFACILITY NUMBER:
455002049
ADMINISTRATOR:NATE ECHOLSFACILITY TYPE:
740
ADDRESS:3030 HERITAGETOWN DRIVETELEPHONE:
(530) 222-8969
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:100CENSUS: 66DATE:
04/24/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:BRENDA SAEPHANTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Resident rights were violated.
Staff are not properly trained to interact with dementia residents.
INVESTIGATION FINDINGS:
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Donna Gurriere and Sarah Benson, Licensing Program Analysts were in contact and met with Brenda Saephan, Manager.

LPAs Gurriere and Benson completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. LPA Gurriere ensured that hand sanitizer was applied before entering the facility.


continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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 6
Control Number 59-AS-20230329135015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: VISTAS ASSISTED LIVING & MEMORY CARE, THE
FACILITY NUMBER: 455002049
VISIT DATE: 04/24/2023
NARRATIVE
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Resident rights were violated.

During the interview process, ten staff persons were interviewed. The residents were observed to be sitting in the living room watching a television program. They were checked in on and spoken to by LPA Gurriere; however, were not interviewed due to their dementia status. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, and Medication Logs. Training documents for staff were obtained and reviewed also.

During the investigation process, it was reported that a resident’s rights were violated when it was suggested by the family that when the resident (Resident 1) asks where his wife is, the staff are to tell him that his wife had died. Staff were interviewed and it was reported that at times, the staff have advised the resident that his wife had died. Due to the resident’s dementia status, it was reported that this caused the resident to be distraught, as he relived the news that his wife had died. It was reported that this issue was addressed in a meeting with staff by the administrator and the manager in which they provided training as to how to interact with the resident.

In addition, it was reported that staff raised their voices at two residents (Resident 2 and Resident 3). It was stated by several persons that they didn’t believe that staff raised their voices; however, but that the staff were “stern” in asking Resident 2 to be seated.

Residents are to be treated with dignity in their personal relationships with staff. Advising a resident several times, that his wife has died is a violation of personal rights, as it was reported that it caused the resident to be distraught. Staff that are stern with a resident indicates an assertion of authority and strictness over a resident. Both examples are personal rights violations.

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(s) are found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 59-AS-20230329135015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: VISTAS ASSISTED LIVING & MEMORY CARE, THE
FACILITY NUMBER: 455002049
VISIT DATE: 04/24/2023
NARRATIVE
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Staff are not properly trained to interact with dementia residents.

During the investigation process, it was stated that because of the reported issue with Resident 1, advising that the resident’s wife had died, the administrator and manager provided training to the staff persons in the dementia unit. In addition, it was reported that staff have been “stern” with Resident 2, which indicates a lack of training of the staff persons. During the interview process, numerous staff persons stated that they felt that they could benefit from additional training.

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(s) are found to be Substantiated. California Code of Regulations, (Title 22), is being 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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230329135015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: VISTAS ASSISTED LIVING & MEMORY CARE, THE
FACILITY NUMBER: 455002049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited
HSC
1569.269(1)(10)
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Personal Rights – To be accorded with dignity in their personal relationships with staff, residents and other persons. To be free from neglect financial exploitation, involuntary seclusion, punishment, humiliation intimidation and verbal, mental physical or sexual abuse.
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The administrator shall arrange for an outside vendor to conduct a personal rights and dementia training for all staff in the dementia unit. The training shall include person-centered approaches to dementia care and understanding dementia behaviors.
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The licensee did not ensure that the personal rights of the residents were implemented.
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Type A
04/25/2023
Section Cited
CCR
87464(d)
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Basic Services - A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs…
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The administrator shall arrange for an outside vendor to conduct a personal rights and dementia training for all staff in the dementia unit. The training shall include person-centered approaches to dementia care and understanding dementia behaviors.
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The licensee did not ensure that the staff were trained to interact appropriately with dementia residents.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
03/29/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230329135015

FACILITY NAME:VISTAS ASSISTED LIVING & MEMORY CARE, THEFACILITY NUMBER:
455002049
ADMINISTRATOR:NATE ECHOLSFACILITY TYPE:
740
ADDRESS:3030 HERITAGETOWN DRIVETELEPHONE:
(530) 222-8969
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:100CENSUS: DATE:
04/24/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:NATE ECHOLSTIME COMPLETED:
10:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following appropriate medication dispensing methods.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Donna Gurriere and Sarah Benson, Licensing Program Analysts were in contact and met with Nate Echols, Administrator.

LPAs Gurriere and Benson completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. LPA Gurriere ensured that hand sanitizer was applied before entering the facility.




continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230329135015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: VISTAS ASSISTED LIVING & MEMORY CARE, THE
FACILITY NUMBER: 455002049
VISIT DATE: 04/24/2023
NARRATIVE
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Staff are not following appropriate medication dispensing methods.

During the interview process, ten staff persons were interviewed. The residents were observed to be sitting in the living room watching a television program. They were checked in on and spoken to by LPA Gurriere; however, were not interviewed due to their dementia status. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, and Medication Logs. Training documents for staff were obtained and reviewed also.

During the investigation process, it had been reported that a staff person rubbed down a pill to make it smaller and then gave it to a resident. Several staff persons were interviewed, and it was reported that staff were unaware of staff not following appropriate medication dispensing methods.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6