455002191-5-12-2022-25-AS-MSEY-CEKPAB-20220519110825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002191
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:43:45 PM

Substantiated

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
01/12/2022 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20220112085642

FACILITY NAME:	SIERRA OAKS OF REDDING MEMORY CARE		FACILITY NUMBER:	455002191
ADMINISTRATOR:	BOBAN, KRISTINE		FACILITY TYPE:	740
ADDRESS:	1620 COLLYER DR		TELEPHONE:	(530) 241-5100
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	0	CENSUS: 68	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kristine Boban, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident eloped from the facility.

INVESTIGATION FINDINGS:

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On 05/11/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Kristina Boban, Administrator. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Administrator (Admin) Kristine Boban.

continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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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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
01/12/2022 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20220112085642

FACILITY NAME:	SIERRA OAKS OF REDDING MEMORY CARE		FACILITY NUMBER:	455002191
ADMINISTRATOR:	BOBAN, KRISTINE		FACILITY TYPE:	740
ADDRESS:	1620 COLLYER DR		TELEPHONE:	(530) 241-5100
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	0	CENSUS: 68	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kristine Boban, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not treat resident with dignity.
Facility staff disregarded authorized representative's decision on calling an ambulance.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220112085642

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: SIERRA OAKS OF REDDING MEMORY CARE	FACILITY NUMBER: 455002191
	VISIT DATE: 05/12/2022

NARRATIVE

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***AMENDED***

This report is amended due to an omitted word

Staff did not treat resident with dignity.

Facility staff disregarded authorized representative's decision on calling an ambulance.

During interviews with Administrator, staff, residents, and records reviewed it was determined that Staff did not treat resident with dignity, Facility staff disregarded authorized representative's decision on calling an ambulance to be un-substantiated. Interviews concluded that staff did not, nor ever have treated any resident without dignity. Facility staff always call Emergency Medical Services (EMS) if there are any emergency situation. Facility felt that R1 was having a mental episode and was a threat to himself as well as other residents. All staff interviewed reported that they have a saying “when in doubt, call it out”. The preponderance of evidence standard has not been met. The allegation is un-substantiated

The preponderance of evidence standard has not been met. The allegations are Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220112085642

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: SIERRA OAKS OF REDDING MEMORY CARE	FACILITY NUMBER: 455002191
	VISIT DATE: 05/12/2022

NARRATIVE

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Resident eloped from the facility.

During interviews with Administrator, staff, and records reviewed, it was determined that Resident eloped from the facility to be substantiated. Through interviews it was found that R1 did climb the facility fence and eloped from the facility about a half of a mile and was found on the side of the road walking by a family member who drove R1 back to the facility.

The allegation is SUBSTANTIATED. A finding of substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited as per Title 22 Regulations and Health and Safety Code.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220112085642

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: SIERRA OAKS OF REDDING MEMORY CARE	FACILITY NUMBER: 455002191
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/13/2022 Section Cited CCR 87705(a)(4)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia. (4) There is an adequate number of direct care staff to support	1 2 3 4 5 6 7	Licensee understands the importance of ensuring there are adequate staff to support each resident's specific needs. Licensee stated R1 is no longer residing at the facility. Licensee agrees to send to CCL their new plan to accommodate the needs of residents with elopement behavior. Licensee to send this plan to CCL by POC date provided.
	8 9 10 11 12 13 14	each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: R1 eloped the facility on 03/23/2021 and there was not a staff member available to ensure R1's safety.	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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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