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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002741
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:25:01 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
02/03/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220203122817
FACILITY NAME:WHITE ROCK SENIORS HOMEFACILITY NUMBER:
515002741
ADMINISTRATOR:NGICHU, LINDAFACILITY TYPE:
740
ADDRESS:490 WHITE ROCK DRIVETELEPHONE:
(916) 616-6464
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:5CENSUS: 2DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Linda Ngichu, administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident fell and sustained a minor injury while in care – SUBSTANTIATED
Staff is requiring advanced notice for resident to have visitors – SUBSTANTIATED
Staff are mismanaging resident's medication- SUBSTANTIATED
INVESTIGATION FINDINGS:
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06/09/2022 2:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Linda Ngichu, administrator for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

During the course of the investigation 1 administrator, and 4 staff were interviewed. LPA obtained the following documents to investigate the above allegations: Physicians Report (LIC602), Preplacement Appraisal, Appraisal/Needs and Services Plan, Admission Agreement, Amendment to placement agreement dated 12/26/2021, Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record, Physician’s Order for New Medication, Discharge Summary from Hospital, Emergency Room Discharge Instructions, Medication List from hospital, Progress Notes.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
VISIT DATE: 06/09/2022
NARRATIVE
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Resident fell and sustained a minor injury while in care – SUBSTANTIATED

Review of discharge instructions for R1 from the local emergency room dated 12/04/2021 included a diagnosis of fall with skin tear of elbow without complication. A CT scan of brain WO contrast was performed on R1 during this visit. R1 was admitted to the ER on 12/04/2021 at 17:11 and discharged at 22:06 the same date.

Review of R1’s LIC602 Physician’s report states that R1 is ambulatory, has mild cognitive impairment, dementia, and requires assistance with toileting needs.

3 of 4 staff stated they were not on duty when the fall occurred, 1 staff stated they were on duty when the fall occurred. Staff 3 (S3) stated that they were assisting a non-ambulatory resident, heard R1 get up and asked them if they could wait for a few minutes. R1 was on the toilet and S3 asked them to wait while S3 helped the other resident. S3 heard a loud noise and discovered that R1 had fallen. S3 called 911 and they assessed R1, cleaned her up, said the wound was superficial and transported R1 to the hospital.

Interview with administrator revealed that Resident 1 (R1) did fall in the facility and the administrator was not present. Staff 3 (S3) was assisting R1 and was asked to assist another resident and stepped out. S3 asked R1 to wait but administrator thinks R1 tried to get up and slipped and fell. 911 was called.

Staff is requiring advanced notice for resident to have visitors - SUBSTANTIATED

During staff interviews 2 staff stated that it is better for visitors to call in advance before visiting, 1 staff stated that visitors are required to call in advance before visiting, and 1 staff stated that they always get a text from the administrator before residents have visitors.

Administrator stated they do not require visitors to make an appointment but to give an alert before visiting. If they have multiple visitors in the facility it is too hard to contain Covid.
Continued on LIC9099-C
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
VISIT DATE: 06/09/2022
NARRATIVE
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Staff are mismanaging resident's medication- SUBSTANTIATED

Interview with administrator revealed that administrator had taken R1 to urgent care on 1/24/2022 and the doctor emailed a prescription order the same day. Administrator was not sure when the medication arrived but was sure the pharmacy delivered it to the facility. LPA confirmed that the medication was logged into the Medication Administration Record (MAR), and in the Centrally Stored Medication on 1/25/2022 with a start date of 1/25/2022, and that the medication was not administered until 1/27/2022.


Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was emailed to administrator Linda Ngichu.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
HSC
1569.2(c)
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1569.2(c) Basic Services Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with ... personal care. This requirement was not met as evidenced by:
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Administrator agrees to conduct staff training on fall prevention and will submit roster with staff signatures as proof of training.
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Based on interviews and records review, it was determined that the facility did not provide care and supervision of R1 resulting in a fall with minor injury which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 6/30/2022.
Type B
06/30/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors... permitted to visit privately... and without prior notice...This requirement is not met as evidenced by:
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Administrator agrees to review visitation policy and CCR 87468.1 with staff and will submit roster with staff signatures as proof of training.
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Based on interviews, Administrator is requesting visitors give advance notice before visiting residents which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 6/30/2022.
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: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee agrees to conduct an in-service medication training with all staff no later than 6/30/2022. Licensee will submit a copy of training and roster with signatures to LPA by 6/30/2022.
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Based on LPAs record review and interview, the administrator failed to provide medication to resident in a timely manner as prescribed. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 6/30/2022.
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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: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
02/03/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220203122817

FACILITY NAME:WHITE ROCK SENIORS HOMEFACILITY NUMBER:
515002741
ADMINISTRATOR:NGICHU, LINDAFACILITY TYPE:
740
ADDRESS:490 WHITE ROCK DRIVETELEPHONE:
(916) 616-6464
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:5CENSUS: 2DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Linda Ngichu, administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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3
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Staff are not providing adequate food service for resident's - UNSUBSTANTIATED
Staff are not combing resident's hair - UNSUBSTANTIATED
Resident lost excessive weight - UNSUBSTANTIATED
Staff removed resident's personal items from room - UNSUBSTANTIATED
Staff allows resident to sleep all day - UNSUBSTANTIATED
Staff are not making sure resident has on correct glasses - UNSUBSTANTIATED
Staff is charging resident extra for time at doctor's appointment - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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06/09/2022 2:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Linda Ngichu, administrator for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

During the course of the investigation 1 administrator, and 3 staff were interviewed. LPA obtained the following documents to investigate the above allegations: Physicians Report (LIC602), Preplacement Appraisal, Appraisal/Needs and Services Plan, Admission Agreement, Amendment to placement agreement dated 12/26/2021, Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record, Physician’s Order for New Medication, Discharge Summary from Hospital, Emergency Room Discharge Instructions, Medication List from hospital, Progress Notes.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
VISIT DATE: 06/09/2022
NARRATIVE
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Staff are not providing adequate food service for residents – UNSUBSTANTIATED
During staff interviews it was learned that residents are served breakfast, lunch, and dinner. Breakfast starts to be served at 7:00 AM but sometimes residents want to sleep in so breakfast is served to them when they wake up and would like to eat.

Administrator stated that breakfast is 7:00 am to 9:00 am. If residents wake up early night shift will give them breakfast.

Staff are not combing resident's hair – UNSUBSTANTIATED
Staff interviews revealed that staff combs the resident’s hair every morning and staff always make sure the residents are groomed and ready to have breakfast.

Administrator stated that resident’s hair is combed every day including after nap time.


Resident lost excessive weight – UNSUBSTANTIATED
Document review of Hospitalist Discharge Summary dated 11/22/2021 and LIC602 Physician’s Report dated 11/24/2021 showed that resident weighed 110 lbs.

Staff interviews revealed that R1 did not lose weight when they lived at the facility. R1 was known to like to snack and ate pretty well when they lived at the facility.

Administrator stated that R1 actually gained weight while living at the facility. R1 ate very well.

Continued on LIC9099-C



SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
VISIT DATE: 06/09/2022
NARRATIVE
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Staff removed resident's personal items from room – UNSUBSTANTIATED
During staff interviews it was learned that staff put some photographs on the shelf in R1’s closet and R1 also had pictures displayed in their room.

Administrator stated that staff moved some pictures from R1’s nightstand onto a shelf in the closet area. Administrator obtained permission from R1’s daughter before doing this. The facility moved the pictures because they were concerned that R1 could fall into them and they would break and cause injury to R1 because they were glass.

Staff allows resident to sleep all day – UNSUBSTANTIATED
During staff interviews it was learned that at night R1 liked to stay up and watch tv and movies and tell staff stories. During the day R1 was tired a lot and If R1 wanted to rest, R1 rested but R1 did not rest all day, R1 liked to nap after meals.
Administrator stated that R1 took a few naps in the day but was more of a night person.

Staff are not making sure resident has on correct glasses – UNSUBSTANTIATED
Staff interviews revealed that R1 wore glasses all of the time. Staff are unsure of what kind of glasses R1 wore but thought they were prescribed by R1’s doctor.

Administrator stated that R1 had a pair of glasses for reading and one for distance. Administrator does not remember R1 walking around in reading glasses.

Continued on LIC9099-C

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 25-AS-20220203122817
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: WHITE ROCK SENIORS HOME
FACILITY NUMBER: 515002741
VISIT DATE: 06/09/2022
NARRATIVE
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Staff is charging resident extra for time at doctor's appointment – UNSUBSTANTIATED
During interview with the administrator it was learned that the administrator had explained to the family that the administrator could take the resident to doctor appointments but would have to get extra staffing to take care of the residents that are in the facility when administrator was at those appointments. When R1 got sick the family said a family member would be able to maintain those doctor visits. Due to Covid the family member changed their mind so the administrator took R1 to the ER and was there for 7 hours. The family objected to the extra charge so the administrator did not charge the family for the ER visit.


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.

An exit interview was conducted. A copy of the report was emailed to facility administrator Linda Ngichu.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9