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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:57:19 PM

Document Has Been Signed on 09/19/2024 01:57 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 HOMEFACILITY NUMBER:
045001436
ADMINISTRATOR/
DIRECTOR:		SERRANO,NORA CHAVEZFACILITY TYPE:
735
ADDRESS:1681 PINE STREETTELEPHONE:
(530) 533-1851
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 AM
MET WITH:Nora Serrano - licensee / administratprTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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09/19/2024 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nora Serrano. The purpose of the visit was to deliver the results of a case management investigation.

Hospital medical records revealed that Client 1 (C1) suffered an avulsion fracture of the left hip consistent with an unwitnessed fall.



C1 received one to one care at Pine Ville Care Home (facility). Staff 1 (S1) was C1’s caregiver in the time period around the time of the injury. S1 denied any rough handling of C1 at any time. S1 also denied C1 had a fall the night of the incident and that C1 never screamed out in pain that day.

Several facility staff described S1 as a lazy worker who would consistently yell at C1 and ignore C1’s cries for help. Facility staff all agree that S1 would routinely conduct improper transfers with C1 which would result in C1 acting out aggressively toward S1.

Clients in care were consistent in stating S1 was mean to C1 on a regular basis. Client 2 (C2) remembered seeing C1 on the floor in their room before dinner the day before C1 was sent to the hospital. C2 stated S1 was with C1 in their room and assisting C1 back into their wheelchair.

Continued on LIC809-C
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 09/19/2024
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According to staff and clients, C1 was fine the day before he was sent to the hospital but during S1’s shift everyone heard C1 screaming in pain. The next morning, C1 was sent to the hospital and diagnosed with a fractured hip. Staff 2 (S2) remembered at around 1930 hours, C1 was heard screaming while they were being transferred into their bed by S1.

C1 was heard screaming during the PM shift and during the NOC shift. During the NOC shift C1 clearly said they were in pain and pointed to their back and groin area but staff did not immediately call for medical aid. Medical aid was called for C1 the next morning as soon as the AM shift staff arrived.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that a client sustained a fracture as a result of neglect / lack of care and supervision by staff is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided.

Violations that result in the injury of a client in care are subject to an immediate civil penalty of $500 per violation. Civil penalty assessed at $500 on 09/19/2024. The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code §1548.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 01:57 PM - It Cannot Be Edited


Created By: Rebecca Knight On 09/19/2024 at 09:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PINE VILLE CARE HOME
FACILITY NUMBER: 045001436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee agrees to conduct a follow-up training for all staff concerning the requirement to supervise clients, observe and acknowledge a client when they complain of pain, provide care for the client, and immediately seek medical attention for the client no matter what time of day the client complains of pain. In addition, the licensee shall conduct training for all staff on methods and requirements of safely transferring clients. Licensee will provide LPA with training subject matter and sign in sheet with dates and staff signatures.
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Based on staff interviews and evidence obtained 1 of 4 clients sustained a fracture as a result of neglect / lack of care and supervision by staff. This poses an immediate health, welfare, and safety hazard to residents in care.
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Proof of correction to be submitted to LPA by 10/03/2024.

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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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