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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002885
Report Date: 01/14/2025
Date Signed: 01/14/2025 08:59:58 AM

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
09/03/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240903151711
FACILITY NAME:ACTING WITH LOVE ASSISTED LIVINGFACILITY NUMBER:
455002885
ADMINISTRATOR:TOMPKINS, TASHAFACILITY TYPE:
740
ADDRESS:2635 SAPPHIRE LANETELEPHONE:
(530) 941-1473
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:12CENSUS: 9DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:LESLIE ROSETIME COMPLETED:
09:10 AM
ALLEGATION(S):
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Facility did not inform Power of Attorney (POA) of change in resident’s medication.
INVESTIGATION FINDINGS:
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On 01/14/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 09/03/24. LPA Gurriere met with Leslie Rose, House Manager and explained the purpose of the visit.

Facility did not inform Power of Attorney (POA) of change in resident’s medication.

During the interview process the administrator and a resident’s family member were interviewed. The resident (Resident 1) was not interviewed as she was sleeping when the LPA was at the facility. Documents were obtained to include the Admission Agreement, Appraisal and Needs Plan and the resident’s Medication Administration Records.

continued

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 2
Control Number 59-AS-20240903151711
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: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885
VISIT DATE: 01/14/2025
NARRATIVE
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During the investigation process, parties that were involved were interviewed and it was reported that when the Physician’s Assistant (PA) was refilling prescriptions for the residents, she made a mistake and called the pharmacy with another resident's medication, and not the medication order for Resident 1. Shortly after the error, the PA realized her mistake, contacted the pharmacy, and canceled the prescription order error. In addition, it was stated that the medication order was never picked up.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2