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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515001365
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:11:58 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
05/30/2023 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230530084440
FACILITY NAME:GARDENS, THEFACILITY NUMBER:
515001365
ADMINISTRATOR:BRANDY STRAHLFACILITY TYPE:
740
ADDRESS:840 WASHINGTON AVENUETELEPHONE:
(530) 790-3075
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:49CENSUS: 30DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Brandy Strahl, ED and Jamie ScottTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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• Staff physically abused resident in care.
• Staff verbally abused resident in care.
INVESTIGATION FINDINGS:
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On 10/19/2023 LPA Tryon visited the facility to complete the complaint. LPA met with Brandy Strahl, ED and Jamie Scott. During the investigation LPA has spoken with witnesses, staff, reviewed documentation and reviewed and obtained police report.
Regarding the allegation that Staff physically abused resident in care and verbally abused resident in care, LPA has spoken with witnesses, staff, reviewed documents, and staff statements. LPA learned that on 01/20/2023 former staff S1 was seen pulling resident R1 forward by their arms repeatedly in their chair at a meal and telling R1 they needed to sit up or S1 would not feed them. This was witnessed by at least 2 other staff members.
In addition, staff S1 was seen pulling resident R2 backwards in their wheelchair. Resident was stating “stop” and that they were being hurt. S1 was also seen transporting resident R3 in their wheelchair with a belt buckled around them. Due to R3’s disability, They are unable to unfasten the seatbelt independently. Staff also witnessed S1 pulling R3 by the arm to get into the dining room.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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-20230530084440
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: GARDENS, THE
FACILITY NUMBER: 515001365
VISIT DATE: 10/19/2023
NARRATIVE
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The facility subsequently did an internal investigation into the above, followed facility personnel procedures, and took appropriate action.

Although the facility took actions against S1, it has been found that S1 was physically and verbally abusive towards residents while employed at the facility. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

A finding of substantiated means that the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, Division six and Chapter eight are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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
05/30/2023 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20230530084440

FACILITY NAME:GARDENS, THEFACILITY NUMBER:
515001365
ADMINISTRATOR:BRANDY STRAHLFACILITY TYPE:
740
ADDRESS:840 WASHINGTON AVENUETELEPHONE:
(530) 790-3075
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:49CENSUS: 30DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Brandy Strahl, ED and Jamie ScottTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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• Staff did not notify the resident’s responsible party of the incidents.
INVESTIGATION FINDINGS:
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Regarding the allegation that the staff did not notify the resident’s responsible party of incidents, LPA has spoken with staff, witnesses, and reviewed reports. It appears that the facility notified responsible parties and appropriate parties when required. It appears that there may have been situations where an individual wanted to be notified about situations at the facility; but did not have the right to be notified of these particular situations as it did not directly concern their family member, but rather another resident of the facility. Therefore, the allegation is Unfounded.

A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted, appeal rights provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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
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
05/30/2023 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20230530084440

FACILITY NAME:GARDENS, THEFACILITY NUMBER:
515001365
ADMINISTRATOR:BRANDY STRAHLFACILITY TYPE:
740
ADDRESS:840 WASHINGTON AVENUETELEPHONE:
(530) 790-3075
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:49CENSUS: 30DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Brandy Strahl, ED and Jamie ScottTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Resident is sexually assaulting other residents in care.
-Resident physically assaulted other residents in care.
-Staff did does not prevent residents from entering other resident's rooms
INVESTIGATION FINDINGS:
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Regarding the allegation that resident is sexually assaulting other residents in care, LPA has spoken with staff, witnesses, reviewed documentation and police report. Police Report dated 3/17/2023 Stated that Yuba City PD was contacted on 3/17/2023 alleging possible sexual assault by a male resident. As per the report, an officer responded to the facility and spoke with residents. In speaking with resident R4, the officer was told that a male resident had entered the room of R4 the previous night. The resident stated when they got out of bed, the man had put his hands on their shoulders and R4 had pushed the individual out of the room. R4 denied any further interaction or assault by the male resident. It is not possible to say with certainty exactly what happened, as residents are in memory care therefore there is a cognitive decline for some residents in this facility. The police did not issue any findings, as R4 did not wish to pursue further action. The allegation is therefore unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20230530084440
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: GARDENS, THE
FACILITY NUMBER: 515001365
VISIT DATE: 10/19/2023
NARRATIVE
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Regarding a resident physically assaulting another resident, staff reported observing a resident going towards another resident, however staff intervened, and no incident took place. There was talk of other residents being “assaulted” but LPA found no information about this, therefore cannot prove or disprove that any assaults actually occurred. Therefore, the allegation is unsubstantiated.

Regarding staff not preventing residents from entering other residents’ rooms, LPA has spoken with staff, witnesses, etc. Based in interviews conducted, R1’s responsible party requested the R1’s bedroom door has the ability to be locked. It was reported that the door was unlocked the next day. It is not possible to say if the door was locked the previous night, who may have unlocked it, why, etc. The resident may have unlocked the door, which they certainly have the right to do. Staff are not able to constantly monitor the lock on one resident’s door to ascertain that it is always locked; and the resident has the right to lock or unlock their own door. The allegation is unsubstantiated.

A finding that an allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230530084440
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: GARDENS, THE
FACILITY NUMBER: 515001365
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily
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The facility immediately followed up regarding these incidents and investigated the situation. S1 was appropriately dealt with by the faciity. The facility also conducted Resident Rights training on DATE with staff to avoid similar situations in the future. POC complete.
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living functions such as eating, sleeping, or elimination.
This requirement was not met as evidenced by:
Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. She also fastened a seatbelt around R2 in her wheelchair when R2 could not unbuckle the belt; and pulled R2 backwards down the hallway, while R2 said to stop, it was hurting; and pulled R3 by the arms down the hallway. This potentially caused an immediate health and safety hazard.
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Type A
10/17/2023
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily
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The facility immediately followed up regarding these incidents and investigated the situation, followed facility procedures and took appropriate action. The facility also conducted Resident Rights training with staff to avoid similar situations in the future. POC complete.
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living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Through interview of staff and review of documentation, LPA learned that staff S1 repeatedly pulled resident R1 by the arms at the dining table and told her to sit forward or she would not feed her. This potentially caused an immediate health and safety hazard.
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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) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6