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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002787
Report Date: 01/03/2024
Date Signed: 01/03/2024 09:07:57 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
11/16/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20231116090319
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:
01/03/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:KRISTINE BOBANTIME COMPLETED:
09:15 AM
ALLEGATION(S):
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Resident sustained an injury from another resident while in care.
INVESTIGATION FINDINGS:
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On 01/03/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 11/16/23. LPA Gurriere met with Kristine Boban, Administrator, and explained the purpose of the visit.

Resident sustained an injury from another resident while in care.

During the interview process, eight staff persons were interviewed. The residents were not interviewed, due to their dementia status. Documents were received and reviewed to include Physician’s Reports, Admission Agreements, Incident Reports and Medications Lists.
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: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 3
Control Number 59-AS-20231116090319
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: 01/03/2024
NARRATIVE
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During the investigation, it was reported that on 10/19/23, a staff person was “shadow boxing” (pretend fighting) with Resident 1. Resident 1 then went to Resident 2 and hit him in the face. Resident 2 fell backwards and sustained an abrasion to the back of his head. Staff heard the altercation and went to the residents and separated them. Staff called emergency services and Resident 2 was sent to the hospital. While at the hospital, the resident’s abrasion was addressed and within a few hours he was sent back to the facility. The staff person that was shadow boxing was terminated from her position.

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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20231116090319
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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2024
Section Cited
HSC
1569.2(c)
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"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.
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The administrator agrees to provide training to staff persons regarding the facility’s protocol of caring for a dementia resident, which shall include appropriate staff interactions with the residents. Administrator shall submit names of staff persons trained and training material to the licensing agency by 01/04/24.
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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.
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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: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3