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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700739
Report Date: 10/16/2024
Date Signed: 10/16/2024 04:51:11 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
07/15/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240715140347
FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 111DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Henry Cole, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
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9
Staff did not prevent resident from being harmed by another resident which resulted in injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 7/15/24. LPA met with Henry Cole, Administrator, and stated the reason for the inspection. LPA was on site most of the day to conduct a required annual inspection also.

The Department conducted an investigation into an incident on 7/13/24 (7:51 am), between residents (R1/R2) in the Memory Care dining room. Interviews were conducted, video surveillance was viewed along with police and hospital records. Video surveillance showed multiple staff had intervened in less than (20) seconds and within (2) minutes, both residents were being assisted with walking out of the dining room. The police were contacted due to (R1) returning to the dining room and yelling. (R1) returned from the hospital the same day at 1:30 pm. (R2) was redirected and assigned a 1:1 for 48 hours to monitor behavior. Based on review of police and hospital medical records, it was determined that an egregious injury was not sustained by (R1).

Based on information obtained, the Department has determined the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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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