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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700963
Report Date: 10/30/2025
Date Signed: 10/30/2025 03:45:39 PM

Substantiated


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
06/03/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250603141930
FACILITY NAME:OARS AT GREENBACK LANE, THEFACILITY NUMBER:
342700963
ADMINISTRATOR:CHRISTAL ANDERSONFACILITY TYPE:
740
ADDRESS:6550 GREENBACK LANETELEPHONE:
(916) 212-0388
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:57CENSUS: 53DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Christal AndersonTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility failed to notify responsible party
INVESTIGATION FINDINGS:
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On 10/30/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 06/03/2025. LPA met with Executive Director (ED) Christal Anderson and explained the purpose of the visit.
During the course of the investigation, the Department conducted interviews and record review.
Interviews revealed that facility was late in telling R1s responsible party of the incident. The incident occurred on 05/26/2025 and facility did not notify residents responsible party in writing within seven (7) days of occurrence. Interviews revealed the family recieved the incident report on 07/22/2025 when R1s file was picked up by their responsible party. Based on file review and interviews, the facility did not ensure incident report was sent to R1s responsible person as required. Therefore the preponderance of evidenced standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of the report and appeal rights left at the facility.  
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cheyenne Ratajczak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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 4
Control Number 59-AS-20250603141930
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: OARS AT GREENBACK LANE, THE
FACILITY NUMBER: 342700963
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2025
Section Cited
CCR
87211(a)(1)(B)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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Licensee is to come up with a procedure on how the facility will ensure families are notified in wiriting within seven (7) days of an incident.
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This requirement is not met as evidenced by: Based on interviews the Licensee did not comply with the section cited above in facility did not notify responsible party in writing within seven (7) days of the incident.
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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.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cheyenne Ratajczak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/03/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250603141930

FACILITY NAME:OARS AT GREENBACK LANE, THEFACILITY NUMBER:
342700963
ADMINISTRATOR:CHRISTAL ANDERSONFACILITY TYPE:
740
ADDRESS:6550 GREENBACK LANETELEPHONE:
(916) 212-0388
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:57CENSUS: DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Christal AndersonTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not ensure care and supervision was provided resulting in resident sustaining a hip fracture
INVESTIGATION FINDINGS:
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On 10/30/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 06/03/2025. LPA met with Executive Director (ED) Christal Anderson and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and record review.


Please contiune to LIC9009C....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cheyenne Ratajczak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250603141930
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: OARS AT GREENBACK LANE, THE
FACILITY NUMBER: 342700963
VISIT DATE: 10/30/2025
NARRATIVE
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Allegation: Staff did not ensure care and supervision was provided resulting in resident sustaining a hip fracture 
On 5/26/2025 Staff #1 (S1) was conducting the last rounds of their shift, when entering Resident #1 (R1s) bedroom. R1 informed staff they needed to go to the restroom. S1 assisted R1 out of bed and R1 had complaints of pain. S1 advised R1 to wait so they could get R1 checked out, but R1 refused, demanding they use the restroom. S1 walked R1 to the toilet, when R1 sat down on the toilet, they “screamed” in pain. S1 called a Med-Tech who had just come on shift for assistance. S1 and Med-Tech escorted R1 to a sofa in their room, sat them down and evaluated them. At this point R1 could not stand up. Several other staff members were interviewed, and they all recalled the same story. S1 escorted R1 to the toilet, R1 called out in pain, and S1 called for help, R1 was evaluated and sent out. No fall during the night was reported. R1 was diagnosed with a “right femoral head, neck fracture.” Several residents were interviewed. All residents interviewed had no complaints about the facility and enjoyed the care they received. R1 was interviewed but due to mild cognitive impairment, they were unable to provide a comment on what occurred. Based on the information obtained during this investigation, it is unknown how R1 sustained their injury. R1 does not require any special checks during the night and was checked on throughout the night, staff reported they were sleeping. Based on R1’s care needs the facility staff acted appropriately per policy. 
Based on this information, this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.   
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cheyenne Ratajczak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4