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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 525002667
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:11:18 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, 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
10/17/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20241017150449
FACILITY NAME:NORTH VALLEY SERVICES-OAK CREEKFACILITY NUMBER:
525002667
ADMINISTRATOR:NUNEZ, MARETTAFACILITY TYPE:
735
ADDRESS:18850 OAK CREEK COURTTELEPHONE:
(530) 527-7987
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY:4CENSUS: 3DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jessica Owens - administratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not ensure health conditions for client were addressed in a timely manner- SUBSTANTIATED
INVESTIGATION FINDINGS:
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12/10/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Jessica Owens. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed administrators and staff. LPA reviewed the following documents: Admission agreement, IPP, LIC600 Physicians Report, Care Plan, Care notes, documentation of medical appointments for the past 2 years, related incident reports for 1 client, staff list with telephone numbers.

Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 4
Control Number 59-AS-20241017150449
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: NORTH VALLEY SERVICES-OAK CREEK
FACILITY NUMBER: 525002667
VISIT DATE: 12/10/2024
NARRATIVE
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Page 2

Staff did not ensure health conditions for client were addressed in a timely manner - SUBSTANTIATED

It was reported that a client was in constant pain for one year, was recently diagnosed with cancer, and the staff at the care home never addressed the client’s health issues.

LPA reviewed Client 1’s (C1) care notes from January 2024 through October 2024. Per care notes on 07/21/2024 C1 complained of stomach pain. C1 complained of stomach pain on and off through 07/30/2024. Per care notes on 08/01/2024 C1 had a medical appointment and was counseled that he needed to drink more water and change his diet. LPA reviewed medical appointment documentation for this 08/01/2024 visit which states that C1 was seen for medication refills with no changes to their medication. There was no mention in the medical appointment documents for this visit of C1 being examined or treated due to stomach pain.

Per care notes on 08/04/2024 C1 complained of stomach pain and continued to complain through 10/17/2024 of stomach pain for a total of 21 complaints to staff. There is no evidence that C1 was taken to a medical appointment after the appointment on 08/01/2024 and before the appointment on 10/04/2024.

LPA reviewed medical appointment document 10/04/2024 Mercy Medical Center Redding. ER for nausea and vomiting. Diagnosed with pancreatic lesions and multiple lesions throughout abdomen. Instructed to follow up with primary care doctor.

Per care notes 10/08/2024 C1 went to a medical appointment. LPA reviewed medical appointment document 10/08/24 Primary care physician medical appointment. ER follow up, review CT scans. Doctor notes Has liver cancer, follow up oncologist.

Per care notes 10/12/2024 C1 was at the doctor all day. LPA reviewed medical appointment document 10/10/2024 Dignity Health Mercy Oncology Center. Consultation.

Continued on LIC9099-C

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

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20241017150449
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: NORTH VALLEY SERVICES-OAK CREEK
FACILITY NUMBER: 525002667
VISIT DATE: 12/10/2024
NARRATIVE
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Per care notes 10/17/2024 911 was called for C1 due to low blood pressure and C1 was transported to hospital. LPA reviewed medical appointment document 10/18/2024 Admitted to Mercy Medical Center Redding due to generalized weakness, C1 was unable to ambulate due to diffuse weakness, therefore he was admitted to the hospital for further nutrition optimization, palliative consult, PT /OT. Hospitalist admitted patient for further management. C1 expired at the hospital in November 2024.

Staff interviews revealed that C1 had been complaining of pain in their stomach from a few months to one year prior to the date of the interviews.

Administrator stated that C1 started to complain of stomach pain in June 2024. Stated C1 went to their doctor right away because C1 is seen monthly by their physician. Stated C1 was diagnosed with kidney stones and possible ulcer and they prescribed C1 medicine for gas in their belly. Stated C1 had been to the ER a couple of times before that.

It was determined that C1 started to complain of stomach pain on 07/21/2024 and was taken to see their physician on 08/01/2024. During this medical appointment his stomach pain was not addressed per the medical appointment records. C1’s stomach pains were not completely addressed until 10/04/2024 when they were diagnosed with pancreatic cancer. Because C1 continued to complain of stomach pain, C1 should have been taken to a physician sooner than 10/04/2024 to address their stomach pain. The client expired due to diagnosis of pancreatic cancer. This allegation is substantiated.

Based on interviews, documents and 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 administrator Jessica Owens.

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

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20241017150449
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: NORTH VALLEY SERVICES-OAK CREEK
FACILITY NUMBER: 525002667
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2025
Section Cited
CCR
80078)a)
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80078(a) Responsibility for Providing Care and Supervision - (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee agrees to conduct a staff training on the requirement for clients to be observed for change of condition and arrangements to be made to see their physician for the complaint if the complaint persists. Licensee agrees to submit training materials, subject matter, and staff sign in sheet to LPA by 01/07/2025 as proof of correction.
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Based on document review and interviews it was determined that due to a lack of care and supervision by staff, C1 was not taken to a physician to be treated for stomach pains although they were complaining of stomach pains starting in July 2024. C1 was not seen by a medical professional to be treated until 10/04/2024 when C1 was diagnosed with pancreatic cancer which poses an immediate health and safety risk to clients in care.
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POC due 01/07/2025.
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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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4