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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002787
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:38:50 PM

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
04/17/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230417091208
FACILITY NAME:SIERRA OAKS OF REDDINGFACILITY NUMBER:
455002787
ADMINISTRATOR:BOBAN, KRISTINEFACILITY TYPE:
740
ADDRESS:1520 COLLYER DR.TELEPHONE:
(530) 241-5100
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:113CENSUS: 74DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kris BobanTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff did not report incident to responsible party
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with

During the investigation the executive director, staff, and witnesses interviewed. Medical records and facility records were reviewed.

Administrator admitted they did not notify the responsible party of R1 that R1 had a fall on April 4, 2023.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The following deficiency was cited per CA Code of Regulations Title 22- refer to the 9099-D.

Exit interview completed and copy of report emailed to Admin.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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-20230417091208
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events ...
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By 01/05/2024, Licensee shall submit a written plan of correction on how they shall ensure staff shall notify resident responsible parties when an incident occurs.
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This report shall include the resident's name ,...; and disposition of the case. Based on record review, the licensee did not comply with the section cited above because staff admitted they didn't notifiy responsible party of a fall, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
04/17/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230417091208

FACILITY NAME:SIERRA OAKS OF REDDINGFACILITY NUMBER:
455002787
ADMINISTRATOR:BOBAN, KRISTINEFACILITY TYPE:
740
ADDRESS:1520 COLLYER DR.TELEPHONE:
(530) 241-5100
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:113CENSUS: 74DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kris BobanTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff not following resident care plan
Staff do not meet resident's dietary needs
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with

During the investigation the executive director, staff, and witnesses were interviewed. Medical records and facility records were reviewed.

Facility records show R1 required a pureed diet. There were notes from staff stating they gave the resident pureed food. A witness stated they found the resident in the lobby with vomit that showed cut up pieces of hot dog and other pieces of food particles. LPA reviewed the menu of the facility, and the menu did not have hot dogs as an option. LPA cannot prove or disprove the allegation because no one else was around to confirm R1’s condition when witness stated they found R1
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20230417091208
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
VISIT DATE: 12/06/2023
NARRATIVE
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Witness also stated R1 was not taken to activities by staff. Staff stated the R1 attended activities when R1 wanted to. Facility notes state the R1 stayed in bed a lot. Title 22 regulations does not allow for staff to force residents to participate in activities. Witness also stated they found R1 soiled each time witness visited R1. Staff stated R1 was checked on a regular basis. LPA was unable to interview R1.

Due to the information gathered, LPA cannot determine the allegations: Staff not following resident care plan and Staff do not meet resident's dietary needs. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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, 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
04/17/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230417091208

FACILITY NAME:SIERRA OAKS OF REDDINGFACILITY NUMBER:
455002787
ADMINISTRATOR:BOBAN, KRISTINEFACILITY TYPE:
740
ADDRESS:1520 COLLYER DR.TELEPHONE:
(530) 241-5100
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:113CENSUS: 74DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kris BobanTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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1. Resident sustained injuries due to staff negligence
2. Staff do not assist residents with obtaining medical care.
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with

During the investigation the executive director, staff, and witnesses were interviewed. Medical records and facility records were reviewed.

1. The medical records stated the resident (R1) had an injury related to a chronic condition and not an immediate traumatic injury. R1 did sustain a fall on April 4, 2023, and facility staff stated the resident had full range of motion of the hand and wrist. R1 was taken to the emergency room on April 16, 2023, and the emergency room documented the injury was a chronic injury and R1 showed no signs of discomfort and the wrist and hand had full range of motion. A second medical appointment at a different hospital on April 20, 2023, stated resident had full range of motion and no signs of discomfort and the injury was not the result of a trauma. Another part of the complaint was that R1 sustained multiple pressure injuries while at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230417091208
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
VISIT DATE: 12/06/2023
NARRATIVE
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Medical records obtained did not mention pressure injuries. LPA interviewed responsible party of R1 and the responsible party stated there were no pressure injuries treated while R1 was at the facility

2. Staff interviews stated R1 did not show any signs of trauma after a fall at the facility nor did R1 have any pressure injuries. LPA obtained a copy of medical records from two different locations, and both stated the resident had a chronic injury and did not mention any pressure injury. The medical records also stated resident did not show any sign of discomfort and had full range of motion of and wrist.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6