342700338-11-15-2021-25-AS-KHOS-C9AJAP-20211201055305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700338
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:59:13 PM

Unsubstantiated

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
07/20/2021 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210720110625

FACILITY NAME:	SIGNATURE LIVING ON STORY RIDGE WAY		FACILITY NUMBER:	342700338
ADMINISTRATOR:	RIMANDO, NORA		FACILITY TYPE:	740
ADDRESS:	8400 STORY RIDGE WAY		TELEPHONE:	(916) 300-5363
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 6	DATE:	11/15/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nerry Rimando-Afable, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.

Resident has sustained multiple unwitnessed falls while in care.

Facility failed to report incident(s).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to deliver findings into the complaint allegations listed above. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home.

During the investigation, LPA toured the facility, reviewed documentation pertinent to the investigation, and interviewed facility staff, residents, and relevant parties.

Allegation: Resident sustained unexplained injuries while in care.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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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Control Number 25-AS-20210720110625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SIGNATURE LIVING ON STORY RIDGE WAY	FACILITY NUMBER: 342700338
	VISIT DATE: 11/15/2021

NARRATIVE

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Interviews with residents (R2, R3, R4) and staff members (S1, S2, S3, S4) indicated that there have been no witnessed instances of staff being rough with residents while receiving care. Review of documentation from hospice care and interview with hospice representative indicated that no unexplained injuries occurred while resident (R1) was receiving care at the facility. Staff care notes from the facility match care notes from hospice services.

Allegation: Resident has sustained multiple unwitnessed falls while in care.

Interviews with R2, R3, R4, S2, S3, S4, and relevant parties indicated that there have not been any witnessed or unwitnessed instances of a resident falling while at the facility. Interviews with R2, R3, R4, S2, S3, S4, and relevant parties also indicate that there have not been any witnessed or unwitnessed instances of R1 falling while living at the facility.

Allegation: Facility failed to report incident(s).

Documentation from hospice care and interview with hospice representative indicates that there have not been any incidents regarding R1 that have not been reported to relevant parties. Hospice documentation indicates that one stage 1 decubitus ulcer sustained by R1 was reported to R1's family. Interviews with staff members S1, S2, S3, S4, and Administrator demonstrate that facility is aware of when to report an incident to Community Care Licensing.

Based on interviews conducted by LPA, observations during inspection, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

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