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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 525002755
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:25:44 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
08/06/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240806135627
FACILITY NAME:LASSEN HOUSE SENIOR LIVINGFACILITY NUMBER:
525002755
ADMINISTRATOR:BRASWELL, NICOLEFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff does not ensure resident's fall monitors are in good repair. – SUBSTANTIATED
INVESTIGATION FINDINGS:
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09/17/2024 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the administrator, memory care director, and care staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s report, Admission Agreement, care plan, care notes for 1 resident, related incident reports.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 6
Control Number 59-AS-20240806135627
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: LASSEN HOUSE SENIOR LIVING
FACILITY NUMBER: 525002755
VISIT DATE: 09/17/2024
NARRATIVE
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Staff does not ensure resident's fall monitors are in good repair. - SUBSTANTIATED

It was reported that Resident 1 is supposed to have fall monitors on their clothing and bed but the monitors were not present.

LPA reviewed R1’s care plan which states “motion detector, must carry at all times. Verify Motion Alarm Is in the MC med room. 2. Make sure its charging. Med Techs Charting.

Executive Director stated R1 has been using fall monitors since March 2024. The family purchased a fall monitor for R1 to wear, this fall monitor mistakenly went through the laundry and the facility reimbursed R1’s responsible party for the ruined monitor. The facility installed a motion detector in R1’s room that reports to the Med Tech laptop.

Memory Care Director (MCD) stated R1’s personal fall monitor got washed, they spoke to R1’s RP and explained what happened. They planned to order a new fall monitor but it was taking too long. MCD told RP they would refund the money for the monitor and RP agreed to this.

It was determined that the facility washed R1’s clothing with their fall monitor still attached to their clothing which damaged the fall monitor and rendered it non-operable. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff does not ensure resident's fall monitors are in good repair is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nicole Braswell

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20240806135627
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: LASSEN HOUSE SENIOR LIVING
FACILITY NUMBER: 525002755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87217(b)
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87217(b) Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by:
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Licensee agrees to replace the ruined fall monitor or refund the cost of the fall monitor to the resident’s responsible party.
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Based on document review and interviews the licensee did not prevent the residents’ personal fall monitor from being laundered and rendered inoperable as a result. This poses a potential Health, Safety and Personal Rights risk to clients in care.
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Licensee refunded the cost of the fall monitor to RP on September 2024 statement. The plan of correction has been completed.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/06/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240806135627

FACILITY NAME:LASSEN HOUSE SENIOR LIVINGFACILITY NUMBER:
525002755
ADMINISTRATOR:BRASWELL, NICOLEFACILITY TYPE:
740
ADDRESS:705 LUTHER RDTELEPHONE:
(530) 529-2900
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:86CENSUS: DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicole Braswell - administratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained an unexplained fall and was left on the floor for an extended period of time. - UNSUBSTANTIATED
Facility is not following admission agreement and is overcharging resident in care. - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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09/17/2024 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Nicole Braswell. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the administrator, memory care director, and care staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s report, Admission Agreement, care plan, care notes for 1 resident, related incident reports.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 6
Control Number 59-AS-20240806135627
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: LASSEN HOUSE SENIOR LIVING
FACILITY NUMBER: 525002755
VISIT DATE: 09/17/2024
NARRATIVE
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Resident sustained an unexplained fall and was left on the floor for an extended period of time. – UNSUBSTANTIATED.

It was reported that Resident 1 fell and it took several hours before they were assisted.

LPA reviewed care plan for R1 which states that R1 has a high fall risk [ADL's/Mobility and Transferring]. R1 has history of falls and has poor safety awareness. Staff are to provide full assistance to resident with walking needs for short distance only. Assist in morning and night during wake-up and bedtime. Nighttime checks- four times per night at 12:00 AM, 2:00 AM, 4:00 AM, 10:00 PM, as needed.

LPA reviewed an internal incident report which states on 07/20/2024 at 1:30 AM care staff heard Resident 1 (R1) calling for help. Staff found R1 in their bathroom on the floor. A Med Tech examined R1 for injury and found that R1 had two minor cuts to their right elbow. Med Tech provided first aid. R1 could not recall how or why they fell. Staff notified R1’s physician, responsible party, and the Executive Director of the incident.

During staff interviews it was learned that staff had done rounds 15 – 30 minutes prior to the fall. Staff asked R1 if they needed to use the restroom and R1 declined. 15 minutes later staff were in the room next door to R1 when they heard R1 call out. Med tech provided first aid for a small cut on R1’s elbow.

Executive Director stated R1 fell in their bathroom on 07/20/2024. R1 had a small cut on their right elbow as a result of the fall. R1 was found by care staff.

Memory Care Director (MCD) stated staff found R1 at about 1:15 AM.

It was determined that during rounds staff had checked on R1 15 minutes before R1 called out for help. The allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20240806135627
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: LASSEN HOUSE SENIOR LIVING
FACILITY NUMBER: 525002755
VISIT DATE: 09/17/2024
NARRATIVE
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Facility is not following admission agreement and is overcharging resident in care. - UNSUBSTANTIATED

It was reported that the facility is overcharging Resident 1 (R1).

LPA reviewed R1’s admission agreement that states “Future adjustments to the Base Rent require 60 days' prior written notice to the resident and/or resident’s legal representative which will include the reason for the increase, the amount of the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident, for which the resident or resident’s representative will be given a two day written notification. Evaluation:” The Service Level Fee shall be reviewed 30 days after the Resident's move-in and then quarterly thereafter, although the Community reserves the right to review the Service Level Fee on a shorter interval when appropriate given changes in the level of service required by the Resident. Future adjustments to the Service Level Fee will take effect at any time following a Growth & Wellness Plan review.”

Executive Director stated Since R1 returned from their last stay in rehab they did come back to the facility at a higher level of care. Per the admission agreement changes to care change the monthly fee.

Memory Care Director stated before R1 returned to the facility from a stay in rehab she spoke with R1’s responsible party (RP) and explained that there would be an increase in monthly fees. The RP signed off on the updated Wellness Plan for R1.

It was determined the facility adhered to their admission agreement. This allegation is unsubstantiated.

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 provided to administrator Nicole Braswell.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6