045001436-2-27-2024-59-AS-RKNT-D2UTBJ-20240227133513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 02/27/2024
Date Signed: 02/27/2024 01:36:05 PM

Document Has Been Signed on 02/27/2024 01:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PINE VILLE CARE HOME		FACILITY NUMBER:	045001436
ADMINISTRATOR:	SERRANO,NORA CHAVEZ		FACILITY TYPE:	735
ADDRESS:	1681 PINE STREET		TELEPHONE:	(530) 533-1851
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY: 6		CENSUS: 5	DATE:	02/27/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Nora Serrano - administrator		TIME COMPLETED:	02:00 PM

NARRATIVE

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02/27/2024 12:15 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nora Serrano. Today’s visit is regarding an incident that occurred on 02/13/2024 and was reported to licensing the same day.

It was reported that on 02/13/2024 6:15 am, Client 1’s (C1) morning one-on-one staff, Staff 1 (S1), saw him in his bed. Night shift one-on-one, Staff 2 (S2), said C1 was in the same position since around 10:00 pm the previous night. Nothing was noted in the ID notes for C1 from the previous day. S1 asked C1 if he could reposition himself and C1 said he was in a lot of pain and didn't want the staff to touch him. S1 noticed a bruise on C1’s left thigh and called 911 to have C1 checked out. C1 was transported to the local ER at around 7:00 am. At ER C1 was prepped for an x-ray on his left leg but when ER staff attempted to perform CT scan C1 was very combative. Blood work was taken to check for possible UTI, results were negative. C1 was admitted to hospital around 3:00 pm that day.

During the visit it was learned that C1 was diagnosed with a fractured hip and subsequently hospitalized. C1 is currently in skilled nursing for rehabilitation.

LPA requested the following documents during the visit: Admission agreement, Physician's Report, IPP, Care Plan for 1 resident, staff list with telephone numbers, staff schedule for the week of 2/11/2024 through 02/18/2024.

This incident requires further investigation.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Nora Serrano.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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