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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 11/04/2021
Date Signed: 11/17/2021 09:32:42 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2021 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210913151841
FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:ROBERTSON, JOHNFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:John Robertson, General Manager TIME COMPLETED:
01:22 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not obtain all required admission documentation prior to admitting residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Amended to change Confidential to Public.
On November 4, 2021, Licensing Program Analyst (LPA DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 25-AS-20210913151841. LPA met with Cartin Jankowski,, Community Relations Director and informed her the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) An N-95 mask was worn. Additionally, LPA was screened by front desk personnel.

On September 13, 2021, The Department received a complaint alleging the facility accepted R1 and R2 and failed to obtain the proper admission documentation. LPA reviewed resident and facility files. Based on records reviewed, R1 and R2 both had the required admission documentation in their files when they were admitted to the facility. This agency has investigated the complaint alleging facility did not obtain all required admission documentation prior to admitting residents. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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