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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 052700992
Report Date: 01/03/2024
Date Signed: 01/03/2024 04:48:45 PM

Unfounded


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
11/22/2023 and conducted by Evaluator Maja Jensen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231122163414
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: 74DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Angelica WhiteTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are retaining a resident that requires a higher level of care
Staff are billing resident for services not provided
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/3/24 at approximately 9:50am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Resident Care Director Angelica White and explained the purpose of today's visit.

During the course of the investigation LPA Jensen conducted interviews with care staff, the Executive Director, and the Resident Care Director. LPA Jensen reviewed records that included Resident 1's (R1's) Admission Agreement, Service Plan, Service Agreement, Memory Care Assessment, Progress Notes, R1's medical records, physician communications, LIC 602's, medication prescription orders, Medication Administration Records, billing invoices, emails between the facility and R1's responsible parties and emails from R1's responsible parties to LPA Jensen.

Allegation 1-Staff are retaining a resident that requires a higher level of care:
LPA Jensen reviewed the records listed above. Continued on LIC 9099C...

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 27-AS-20231122163414
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: 01/03/2024
NARRATIVE
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 There are no records that would indicate R1 requires a higher level of care then what the facility is able to provide. There are no medical records stating the resident requires a nursing facility or is inappropriately placed. During the course of interviews conducted, both the Resident Care Director and Executive Director indicated that they discussed with R1's responsible parties that in their opinion, R1 would benefit from having access to a larger, more secure outdoor area due to exit seeking behaviors. There was no evidence found to support that the facility staff was prohibiting R1's responsible parties from relocating R1 if they felt a higher level of care was warranted. Based on the records reviewed and the interviews conducted the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

Allegation 2 - Staff are billing resident for services not provided:
LPA Jensen reviewed the most recent Service Plan, Service Agreement and Memory Care Assessment. The Service Agreement specifies various services including but not limited to extreme weather monitoring, elopement risk and behaviors. The Service Agreement indicates how many providers are needed during which shifts and the frequency of the service needed. While each individual service is listed as having an estimated monthly cost of zero, there is a section that provides for the level of care and pricing information which is derived by multiplying the point value of an assessment conducted by a given dollar amount. This Service Agreement was signed by the responsible party on 9/1/23. The Service Agreement is directly correlated to the Service Plan which lists services that will be provided and adds specific notes as to what those services entail. The Memory Care Assessment lists various activities of daily living, functional capabilities, cognitive capabilities and psycho/social capabilities with each category being assigned a point value. R1 was charged for additional services based on the needs outlined in the Service Agreement, Service Plan and Memory Care Assessment collectively. LPA Jensen conducted interviews with care staff and reviewed progress notes which confirm that R1 was receiving services related to exit seeking behaviors and declining cognitive function. LPA Jensen compared R1's physician report from the time of admission to current and confirmed that R1 has had a deterioration of condition thus warranting a new service plan arrangement. While the service plan and service agreement may be perceived as convoluted and unnecessarily difficult to understand they appear to be in compliance therefore the allegation is UNFOUNDED. A finding 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, appeal rights and the LIC 811 was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/22/2023 and conducted by Evaluator Maja Jensen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231122163414

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:
01/03/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Angelica WhiteTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not bring resident's change of conditon to the attention of the resident's physician
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/3/24 at approximately 3:00pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen mey with Resident Care Director Angelica White and explained the purpose of today's visit.

During the course of the investigation LPA Jensen conducted interviews with care staff, the Executive Director, and the Resident Care Director. LPA Jensen also reviewed records that included but were not limted to Progress Notes, R1's medical records, physician communication forms, LIC 602's, medication prescription orders, Medication Administration Records, emails between the facility and R1's responsible parties and emails from R1's responsible parties to LPA Jensen. Based on the interviews conducted and records reviewed changes in condition identified by care staff were brought to the attention of the Resident Care Director and or medication technician, logged in progress notes and communicated to the physician and responsible parties in a timely manner therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 4
Control Number 27-AS-20231122163414
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: 01/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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, appeal rights and an LIC 811 was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4