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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002787
Report Date: 02/10/2026
Date Signed: 02/10/2026 03:32:42 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
10/10/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20251010084933
FACILITY NAME:SIERRA OAKS OF REDDINGFACILITY NUMBER:
455002787
ADMINISTRATOR:STEVENS, JACOBFACILITY TYPE:
740
ADDRESS:1520 COLLYER DR.TELEPHONE:
(530) 241-5100
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:113CENSUS: 78DATE:
02/10/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Mike LangTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Due to staff negligence, resident missed medications.
Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation.
Due to staff neglect, resident was left to lye in feces for an extended period of time.
INVESTIGATION FINDINGS:
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On February 10, 2026 Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/10/25. LPA Benson met with Administrator Mike Lang Chief Operating Officer for Lenity Pat Brown and explained the purpose of the visit.

During the interview process, staff and witnesses were interviewed. The following documents were received and reviewed: staff schedule, staff list with telephone numbers, MAR, Observation notes, Service Plan and admission agreements.

Continued on LIC9099C & LIC9099D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
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 5
Control Number 59-AS-20251010084933
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
VISIT DATE: 02/10/2026
NARRATIVE
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Due to staff negligence, resident missed medications.
The MAR review revealed the C medication was not administered on October first, second and seventh at 12p.m. MAR review revealed that the C medication was on administered on October sixth or ninth at 8p.m. The MAR review also revealed the C medication was not administered on October eight or ninth for 10p.m. shift, with no notations on MAR for missing medications.

During the investigation with staff interviews it was reported that medication was not given as the facility had run out of oral syringes. Staff five stated we did run out of oral syringes and I used one from house three, some of the other staff didn’t know to go borrow from house three, so the medication was not given.

Staff five stated there were medication technicians that were afraid to give R1 his pain medication, stating that it was too much. Staff four stated when R1’s medication was put in the computer incorrectly and medications were missed because they didn’t show up on his list of medications for R1. Staff four stated there was a few times R1 didn’t receive his medication as I was not trained in how to crush it and put it in a syringe.

Record review revealed the facility was out of stock for three of the residents’ medications, one of the medication was out of stock for seven days. Record review revealed multiple medications on multiple days were not recorded as given. Substantiated.

Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation.



It was reported that the resident was wedged between the wall and bed moaning in pain with no care staff insight.

Staff four stated R1 didn’t like his feet covered and he would kick his feet off the bed trying to get the blankets off of his feet. Staff three S3 stated I heard about that, S3 stated the bed was supposed to be up against the wall and locked. S3 stated the bed wasn’t locked because that is how R1 scooted between the bed and the wall. Staff six stated I’ve seen R1 get wedged more than once, he is trying to get to the chair. Substantiated.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20251010084933
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
VISIT DATE: 02/10/2026
NARRATIVE
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Due to staff neglect, resident was left to lye in feces for an extended period of time.

It was reported that the resident was found with dried feces and a rash on lower extremities.

During the interview process S4 stated I have witnessed poo left on the residents, but not sure if it was R1. S2 stated it should have been recorded in the care note for that day, when R1 was toileted. S3 stated one time I witnessed that R1 was soiled, and I could tell it had been for quite a while. S2 stated yes, I heard about this from another staff, saying family complained and we need to check R1 every hour or two. S4 stated hospice residents should be checked every 30 minutes when they are at end of life. S7 stated I would come to work in the morning and R1 was soiled with feces was dried on, R1’s sheets would be soaked and the place smelled. S7 stated it happened numerous times and I reported it to my supervisor.

The residents care plan states R1 is incontinent of bowels and needs to be checked throughout the shift for any bowel movements. LPA was unable to perform record reviews for BMs as the facility is unable to provide the BM records. Substantiated.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20251010084933
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2026
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will have a medication training with staff.
Administrator will notify LPA with a copy of staff training sign in.
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This requirement is not met as evidenced by:
Based on observation, interviews and record review, the licensee did not ensure the resident was assisted with medications.
Which : poses an immediate Health, Safety or Personal Rights risk to persons in care.

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Type B
03/10/2026
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2)(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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Administrator will have a training with staff concerning the safety of accommodations for the residents.
Administrator will have a training with staff concerning what is required for care notes.
Administrator will notify LPA with a copy of training sign in.
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Based on observation, interviews and record review, the licensee did not ensure the residents have safe, healthful and comfortable accommodations as the resident was wedged between the bed and wall for an unknow amount of time. Which poses a potential Health, Safety or Personal Rights risk to persons 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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20251010084933
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: SIERRA OAKS OF REDDING
FACILITY NUMBER: 455002787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2026
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator will have a staff training concerning the importance of keeping residents clean and dry.


Administrator will notify LPA with a copy of training sign in when completed.
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This requirement is not met as evidenced by: the resident was found soiled. Which poses a potential Health, Safety or Personal Rights risk to persons 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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5