Pines, The

Licensing Program Analyst (LPA) Cassie Yang and Associate Governmental Program Analyst (AGPA) Dana Garcia arrived unannounced at the facility to investigate the allegation of the complaint. LPA and AGPA met with Executive Director and explained the purpose of the visit. The course of the investigation, LPA conducted extensive interviews and file review of R1's records. For the allegation cited above, Unlawful eviction, based on the information provided, it is substantiated. Please continue on LIC 9099-C. Substantiated— CDSS inspection report, June 26, 2025 · control 59-AS-20250619113826

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 egregiousRead the full finding— CDSS inspection report, October 16, 2024 · control 59-AS-20240715140347

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 4/9/24. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection. During the course of the investigation, LPA interviewed the Administrator, Memory Care Director, (5) staff, resident (R1) and (2) family members of (R1's) conservator. LPA reviewed documentation related to (R1's) conservatorship and viewed facility video footage from 4/6/24. The results of the investigation are as follows: Allegation: Staff allowed conserved resident to sign unauthorized forms. The allegation states that resident (R1's) family member visited on 4/6/24, along with an unidentified male, and asked (R1) to sign some documents without the conservator's consent. Cont on 9099C-1... UnsubstantiatedRead the full finding— CDSS inspection report, April 26, 2024 · control 59-AS-20240409113054

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence a complaint investigation. Also present to conduct a joint investigation was an Ombudsman. LPA met with Henry Cole, Administrator, in his office and stated the reason for the inspection. During today's inspection, LPA and Ombudsman discussed the allegations with the Administrator, (2) staff, resident (R1) and a family member of R1's conservator. LPA also reviewed video camera footage and the visitor sign-in log for Monday, April 8, 2024, and discussed the facility's visitor's policy as stated in the Resident Handbook. The findings are as follows for the (1) above allegation: Facility did not follow its visitor policy. The other (2) allegations need additional investigation before a finding can be delivered. cont on 9099C-1... SubstantiatedRead the full finding— CDSS inspection report, April 12, 2024 · control 59-AS-20240409113054

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Henry Cole during today's facility visit. LPA investigated allegation of “Staff does not ensure resident's nail care needs are being met.” LPA interviewed facility staff, responsible parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R1’s fingernails and toenails were not being managed and were very long. Relevant party sent photographs, and LPA observed R1’s fingernails appearing to be overgrown and long. LPA interviewed administrator in which he stated R1 receives visits from a podiatrist every quarter. LPA observed podiatrist documentation in which it states R1 was seen on 11/22/21,4/05/22, 6/20/22, 8/17/22, 10/28/22, 01/17/23, 4/19/23. Continuation on 9099-C. UnfoundedRead the full finding— CDSS inspection report, October 4, 2023 · control 59-AS-20230804135453

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Henry Cole during today's visit. LPA investigated allegation, "Facility dishwasher is in despair" and "Staff are not properly cleaning". LPA interviewed staff and completed a facility tour. Administrator stated the dishwasher in the kitchen is broken but they have leased a dishwasher through an outside vendor and are waiting for the dishwasher to be delivered. Staff have been serving residents with disposable silverware and plates until the new dishwasher is delivered and installed. The kitchen staff have been manually washing pots and pans per the kitchen instructions. Continuation on 9099-C. UnfoundedRead the full finding— CDSS inspection report, July 10, 2023 · control 59-AS-20230706103301

On June 9, 2023, Licensing Program Analyst, (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #25-AS-20220712132307. LPA met with Mira Marcus, BusinessOffice Director, and informed her the reason for the visit. The department received a complaint on July 22, 2022 alleging facility did not conduct a pre-admission appraisal on resident in care, Resident is not being allowed visitations while in care, resident is not being allowed visitation, resident is not provided access to a phone, resident is not being permitted to receive mail, and resident is not being accorded privacy. LPA has reviewed facility files, interviewed residents, staff, witnesses. Residents 1 and 2 are a married couple who reside together at the facility. R1 and R2 were admitted to the facility on 08/26/2021. Based on records review, the facility conducted a pre-admission appraisal for R1 and R2 as well as all completed all other required documentation at the time of admission. AllegationRead the full finding— CDSS inspection report, June 9, 2023 · control 25-AS-20220712132307

On April 14 2023, Licensing Program Analyst DeAnna Williams Lyons arrived to deliver findings. LPA met with Executive Director, Henry Cole, and informed him the reason for the visit. Prior to initiating the visit LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE). On 4/29/2022, the Sacramento North Adult and Senior Care Regional Office (RO) received a complaint regarding staff failing to follow medication order leading to the death of Resident 1 (R1). Allegation: Facility staff failed to follow medication order leading to resident's death. Resident (R1), was admitted to The Pines (TP) on 4/16/2021.On 4/19/2022, R1 had medication orders from their doctor indicating new medication orders. To continue see 9099C... UnsubstantiatedRead the full finding— CDSS inspection report, April 14, 2023 · control 25-AS-20220429171119