525002623-7-1-2025-59-AS-RKNT-DJ6Q9T-20250701115851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002623
Report Date: 07/01/2025
Date Signed: 07/01/2025 11:59:39 AM

Document Has Been Signed on 07/01/2025 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BY THE RIVER ASSISTED LIVING		FACILITY NUMBER:	525002623
ADMINISTRATOR/ DIRECTOR:	O'SULLIVAN, LINDA KAY		FACILITY TYPE:	740
ADDRESS:	1095 LAKESIDE DRIVE		TELEPHONE:	(530) 727-9010
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	07/01/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Mark & Linda O’Sullivan - licensees		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE

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07/01/2025 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with licensees Mark & Linda O’Sullivan, and care staff Lindsey Lang. Today’s visit is regarding an incident that occurred on 06/29/2025 and was reported to licensing on 06/30/2025.

It was reported that on 06/29/2025 at 3:30 PM Staff 1 (S1) saw Resident 1 (R1) heading to their room. At 04:50 PM S1 went to get R1 from their room for dinner, R1 was not in their room. S1 found R1 in the facility backyard almost laying down against the chicken coop. S1 checked R1 for breathing, heartbeat, and awareness. S1 carried R1 inside and placed R1 on a recliner. S1 placed ice packs wrapped in towels and wet wash cloth on R1's forehead, then called 911. R1 stopped breathing, S1 started CPR. EMS arrived and took over. R1 passed away in the facility.

According to The City of Red Bluff past weather report the temperature was 106 degrees at 3:53 PM on 06/29/2025 as a high for that day.

LPA requested the following documents during the visit: Admission agreement, Physicians Report, MAR for one resident, staffing schedule for the date of June 29 2025, meal schedule.

Continued on LIC809-C

Lauren Crocker	TELEPHONE: (916) 261-4966
Rebecca Knight	TELEPHONE: (530) 356-2841
	DATE: 07/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BY THE RIVER ASSISTED LIVING	FACILITY NUMBER: 525002623
	VISIT DATE: 07/01/2025

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Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the 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 licensee Linda O’Sullivan.

At the time of the case management visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations § 87411(a) and is documented on the attached LIC421.

The licensee has been informed that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2025 11:59 AM - It Cannot Be Edited

Created By: Rebecca Knight On 07/01/2025 at 09:19 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BY THE RIVER ASSISTED LIVING	FACILITY NUMBER: 525002623
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/01/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2025 Section Cited	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on records review it was determined that the licensee failed to provide adequate care and supervision to R1 which resulted in R1 going out to the back yard of the facility on a hot day unknown to staff. This resulted in the death of the resident which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 07/15/2025.
	1 2 3 4 5 6 7
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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.

	Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (916) 261-4966

	Rebecca Knight
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (530) 356-2841

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC809 (FAS) - (06/04)

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