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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 525000364
Report Date: 06/05/2023
Date Signed: 06/05/2023 10:48:00 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2023 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20230328160103
FACILITY NAME:NORTHERN OAKSFACILITY NUMBER:
525000364
ADMINISTRATOR:BREWER, JESSICAFACILITY TYPE:
735
ADDRESS:14119 BAKER ROADTELEPHONE:
(530) 527-9454
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:4CENSUS: 3DATE:
06/05/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Kilkrease - administratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not treat client with dignity and respect – SUBSTANTIATED



INVESTIGATION FINDINGS:
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05/31/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Jessica Kilkrease. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation 1 administrator, 1 client, 1 facility staff , 2 day program work staff were interviewed. LPA requested and reviewed the following documents: related incident reports, Physician’s report, Admission Agreement, IPP for 1 client, staff list with telephone numbers, client list.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 5
Control Number 59-AS-20230328160103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: NORTHERN OAKS
FACILITY NUMBER: 525000364
VISIT DATE: 06/05/2023
NARRATIVE
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Staff did not treat client with dignity and respect – SUBSTANTIATED

It was reported that Staff (S1) took photographs of Client 1 (C1) in front of co-workers in their soiled clothes after C1 had an accident.

C1 stated S1 was helping them. C1 stated that S1 did take photographs of C1 to show the licensee.

A witness stated S1 started taking pictures of C1, C1 was very embarrassed and upset.

S1 stated I asked C1 if I could take a picture to send to the licensee because he wanted to know what was going on and C1 said Yes.

Administrator stated facility staff received a call from work program that C1 was covered in excrement and they could not put him in the vehicle. S1 took a photograph of C1 because they wanted to show the licensee that C1 was not covered in it.

It was determined that S1 did take photographs of C1 in their soiled clothes after C1 had an accident in front of co-workers which embarrassed C1. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is 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 provided to administrator Jessica Kilkrease.

Continued on LIC9099-D

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230328160103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: NORTHERN OAKS
FACILITY NUMBER: 525000364
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2023
Section Cited
CCR
80072
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80072 (a)(3) Personal Rights - (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from … humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. This requirement is not met as evidenced by:
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Licensee agrees to provide personal rights training for all direct care and administrative staff particularly concerning treating clients with dignity and respect. Licensee will schedule the training and provide LPA with the training content and signed staff attendance sheet as the POC.
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Based on interviews, it was determined that S1 did take photographs of C1 in their soiled clothes after they had an accident in front of co-workers. 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 6/20/2023.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2023 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20230328160103

FACILITY NAME:NORTHERN OAKSFACILITY NUMBER:
525000364
ADMINISTRATOR:BREWER, JESSICAFACILITY TYPE:
735
ADDRESS:14119 BAKER ROADTELEPHONE:
(530) 527-9454
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:4CENSUS: 3DATE:
06/05/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Brewer - administratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff yelled at client – UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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05/31/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Jessica Kilkrease. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation 1 administrator, 1 client, 1 facility staff , 2 day program work staff were interviewed. LPA requested and reviewed the following documents: related incident reports, Physician’s report, Admission Agreement, IPP for 1 client, staff list with telephone numbers, client list.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
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 5
Control Number 59-AS-20230328160103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: NORTHERN OAKS
FACILITY NUMBER: 525000364
VISIT DATE: 06/05/2023
NARRATIVE
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Staff yelled at client – UNSUBSTANTIATED

It was reported that Staff 1 (S1) yelled at Client 1 (C1).

C1 stated that S1 did not yell at them and S1 was helping C1.

S1 stated if they came across grumpy and grouchy they apologize.

Administrator stated when S1 arrived to pick up C1, S1 asked C1 where the excrement was. C1 showed S1 and they went home.

It was determined that although S1 was gruff with work staff they did not yell at C1. This allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

Exit interview was conducted and the report was provided to administrator Jessica Kilkrease.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5