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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515001963
Report Date: 08/18/2022
Date Signed: 08/18/2022 12:09:51 PM

Unfounded


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
08/15/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220815124318
FACILITY NAME:WILLOW GLEN CARE CENTERFACILITY NUMBER:
515001963
ADMINISTRATOR:GILBERT, DAVIDFACILITY TYPE:
740
ADDRESS:1547 PLUMAS COURTTELEPHONE:
(530) 751-9900
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:60CENSUS: 59DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angie Karis, Faclity ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not intervene in resident’s physical altercation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.

LPA Hiratsuka, investigated the allegation “Staff did not intervene in resident’s physical altercation.” LPA interviewed staff and residents. LPA also obtained information regarding both residents in question. LPA also toured the facility.

Title 22 Regulations and the CA Health and Safety Code does not require staff to be with residents every minute of the day. The incident did occur; however, interviews with the residents indicated staff did intervene as soon as possible. The residents stated staff do intervene as soon as they see something happening.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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 2
Control Number 25-AS-20220815124318
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: WILLOW GLEN CARE CENTER
FACILITY NUMBER: 515001963
VISIT DATE: 08/18/2022
NARRATIVE
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The residents stated this occurred when one approached the other and one hit the other before staff could get there. Both stated they are told to keep distance from each other by staff on a regular basis. Both have been assessed multiple times and have had counseling regarding their relationships.

LPA observed staff walking the hallways, residents in the hallways, their bedrooms, and outside courtyards. LPA observed interactions between staff and residents while touring the facility. Some residents sit in areas that are not in areas that are not in line of sight, but staff are walking around.

“This agency has investigated the complaint alleging; Staff did not intervene in resident’s physical altercation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2