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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:30:02 PM

Document Has Been Signed on 11/14/2024 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR/
DIRECTOR:		PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 100CENSUS: 77DATE:
11/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Keith Payne, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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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 follow-up on additional findings discovered during a complaint investigation #59-AS-20241104155417.

During the course of the investigation, it was discovered that staff (S3), who is a former staff member, went to visit residents (R1 & R2) on 11/2/24. S3 was to request prior written approval from the ED in order to visit R1 and R2. S3 did not request approval and was informed by staff (S1 and S2) that they needed to leave the facility. Interviews conducted with R1 and R2 indicated that staff did not ask S3 to leave in a respectful manner. R1 and R2 indicated that the visit was ended abruptly and the conversation with S3 was done in front of both residents leaving them confused as to why S3 needed to leave. R1 and R2 stated that their front door was open and that the conversation with S3 was in the hallway in front of their apartment. Interviews with staff (S1, S2, and S3) indicated that the conversation regarding S3 needing to leave the facility was in the hallway in front of R1 and R2's doorway. R1 and R2 indicated that the situation could have been handled differently and that S1 and S2 could have talked to S3 in private. R1 and R2 were not accorded dignity in their personal relationships with staff and other persons.

As a result of today's visit, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87468.1(a)(1) regarding personal rights of residents in all facilities. The deficiency is listed on the LIC809-D.

Exit interview conducted. A copy of this report and appeal rights were 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 03:30 PM - It Cannot Be Edited


Created By: Angela Hood On 11/14/2024 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANSEL PARK SENIOR LIVING COMMUNITY
FACILITY NUMBER: 312700574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Facility agrees to complete a statement of understanding and train staff on how to handle situations when a former staff member arrives at the care home to visit residents and submit to LPA by the POC due date of 11/28/24.
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Based on interviews conducted, the facility did not ensure that residents (R1 and R2) were accorded dignity when their visitor, former staff (S3), was told to leave the facility, which poses a potential health, safety, and personal rights risk to 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.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Angela Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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