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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 052700992
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:57:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/18/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230918151004
FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 76DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary McClureTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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The full-time employee is not qualified by formal training or experience for the operation of the food service.
The person in the kitchen lead or chef is not a nutritionist, a dietitian, or a home economist and they are not regularly consulting with the facility
Food temperatures are not right
INVESTIGATION FINDINGS:
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On 11/16/23 at approximately 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Mary McClure and explained the purpose of today's visit.

LPA Jensen reviewed the training records for 4 of 4 kitchen staff and determined them to be in compliance. Based on LPA Jensen's kitchen staff file reviews the allegation of "the full-time employee is not qualified by formal training or experience for the operation of the food service" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

LPA Jensen reviewed documentation related to the facility Registered Dietician Nutritionist (RDN). The facility contract with the RDN is quarterly and she conducts a review of a 4-6 week menu cycle. In addition the RDN is available "as needed" in an on call capacity. Continued on LIC 9099C...


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/18/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230918151004

FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary McClureTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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There are no records of the consultation from a nutritionist, a dietitian, or a home economist.
INVESTIGATION FINDINGS:
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On 11/16/23 at approximately 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Mary McClure and explained the purpose of today's visit.

LPA Jensen reviewed documentation related to the facility Registered Dietician Nutritionist (RDN). The facility contract with the RDN is quarterly and she conducts a review of a 4-6 week menu cycle. In addition the RDN is available "as needed" in an on call capacity. In addition, the facility held a meeting on 8/28/23 called "Meet the Nutritionist" wherein the RDN met with residents to give information on the following:

-Daily Nutrition Requirements
-Why/When recommendations are made to the menu
-How the RDN reviews the menu
-What choices should you make if you are borderline diabetic

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20230918151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 11/16/2023
NARRATIVE
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Continued from LIC 9099A...

-What nutrients you should be most concerned with as a senior
-Special diets

Based on LPA Jensen's review of RDN consultation documentation, the allegation of "there are no records of the consultation from a nutritionist, a dietitian, or a home economist" are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20230918151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 11/16/2023
NARRATIVE
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LPA Jensen reviewed a copy of the menu posted for September 2023. Meals listed for breakfast lunch and dinner appeared to meet the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. Meals included a variety of grains, fruits, vegetables and proteins. Based on LPA Jensen's review of RDN consultation documentation and the facility food service menus the allegation of "The person in the kitchen lead or chef is not a nutritionist, a dietitian, or a home economist and they are not regularly consulting with the facility." is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

LPA Jensen conducted site visits and inspected the facility kitchen on 9/27/23 and 11/16/23. During the course of the kitchen inspection on both occasions LPA Jensen observed the refrigerator and freezer temperatures to be in compliance therefore the allegation of "food temperatures are not right" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
09/18/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230918151004

FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary McClureTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Kitchen is not clean
INVESTIGATION FINDINGS:
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On 11/16/23 at approximately 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Mary McClure and explained the purpose of today's visit.

LPA Jensen conducted site visits and inspected the facility kitchen on 9/27/23 and 11/16/23. LPA Jensen observed debris in the refrigerators, debris in the kitchen corners, debris in the floor drain, oil splatter build up on the deep fryer and waste build up on teh exterior of the garbage can. LPA Jensen observed other areas of the kitchen to be sanitary. Based on LPA's observation of the kitchen the allegation of "Kitchen is not clean" is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met.

Deficiencies are being cited from the Califor ia Code of Regulations (CCR) Title 22, Division 6. An exit interview was coinducted and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20230918151004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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The Licensee agrees to conduct a deep cleaning of the kitchen and send photos to LPA Jensen by 11/23/23.
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Based on LPA Jensen's observation of debris in various locations in the kitchen. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6