577001215-4-21-2023-21-AS-KMOA-CRAV85-20230427161210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577001215
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:05:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20230320123317

FACILITY NAME:	UNIVERSITY RETIREMENT COMMUNITY AT DAVIS		FACILITY NUMBER:	577001215
ADMINISTRATOR:	MARIA BURTON		FACILITY TYPE:	741
ADDRESS:	1515 SHASTA DRIVE		TELEPHONE:	(530) 747-7000
CITY:	DAVIS	STATE: CA	ZIP CODE:	95616
CAPACITY:	500	CENSUS: 305	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Maria Burton, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility does not provide a safe environment for residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at University Retirement Community at Davis for the purpose of delivering complaint findings. LPA met with Administrator Maria Burton and was granted access into the facility.

During the course of the investigation, LPA Nakagawa interviewed staff and various outside parties. LPA toured the facility on March 23, 2023 and April 21, 2023.

Complaint alleges that Facility does not provide a safe environment for residents in care. Complainant alleges that bed rails allowed to be installed on bed caused the bed to come crashing down and break the patient’s back. LPA found that the resident (R1) had suffered a fall on 01/30/23, and several fractures of the lumbar-vertebra with routine healing had been detected during ER visit of the same day.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230320123317

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: UNIVERSITY RETIREMENT COMMUNITY AT DAVIS	FACILITY NUMBER: 577001215
	VISIT DATE: 04/21/2023

NARRATIVE

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Continued from 9099

On 02/02/2023, the bed of R1 did malfunction, due to rails impeding bed being lowered, which was documented. R1 was sent to the Emergency Department at hospital on 02/02/23 at 0200 to make sure no injuries were sustained. This was affirmed and R1 was returned to the facility, with no new injuries or fractures, from Emergency Department on 02/02/23 at 0610. Based on review of documentation, inspection of the facility, and interviews the allegation that the Facility does not provide a safe environment for residents in care is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Complaint also alleges that millions of dollars of building construction are done on resident rooms all without permits; work not inspected from structural work in room (#) and electrical work done all without permits. LPA toured the facility and found the room in question, was having general maintenance being performed, but no walls being moved. Work was being completed by a licensed general contractor, with the State of California. Additional concern was regarding automatic fire doors, which were in place at the end of the hallways, and operational. Therefore, based on inspection, and interviews the allegation that the Facility does not provide a safe environment for residents in care is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies found at the time of inspection. No citations issued.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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