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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700574
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:29:09 PM

Unsubstantiated


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
11/04/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241104155417
FACILITY NAME:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 77DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Keith Payne, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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-Staff interfered with the residents' visitation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 11/14/24, and met with the Executive Director (ED), Keith Payne, to deliver complaint investigation findings into the above stated allegation.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

Interviews with staff (S1, S2, and S3) indicated that S3, who is a former staff member, arrived at the care home on 11/2/24 to visit residents (R1 & R2). Interviews with S2, S3, R1, and R2 indicated that S3 signed in at the front desk to visit R1 and R2. Interview with S2 indicated that they contacted the ED by phone and informed them that S3 was in the building visiting R1 and R2. According to Human Resources, ED, and S2, S3 is required to obtain written approval from the ED prior to visiting any residents at the care home.
**********************************************Continued on LIC9099-C**************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 2
Control Number 59-AS-20241104155417
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: ANSEL PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 312700574
VISIT DATE: 11/14/2024
NARRATIVE
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According to the Associate Handbook approved by CCLD, dated August 2019, "Any associate who voluntarily resigns or is terminated will not be afforded the privilege of having access to our community in order to visit residents as they please. A former associate can no longer visit the community without first obtaining the written approval of the Executive Director prior to visiting a resident". Interview with Human Resources indicated that S3 was familiar with the Associate Handbook and had actively followed protocol with terminated staff members while they were employed at the care home. Human Resources also provided LPA with a letter that was sent to S3 on June 14, 2024 indicating the information from the Associate Handbook regarding visiting residents in the care home.

Interviews with ED, S3, R1, and R2 indicated that S3 did not seek prior approval before visiting R1 and R2.
Interviews with R1, R2 and resident (R3) indicated that they are able to receive visits at the care home.

Based on documentation and interviews conducted, 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. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2