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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001756
Report Date: 11/05/2020
Date Signed: 11/05/2020 12:31:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 19DATE:
11/05/2020
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Cliff KeeneTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/5/20 at 1030 Am, Licensing Program Analyst (LPA) Jaclyn Avila conducted an announced case management visit and met with Administrator Cliff Keene. Precautionary measures were taken regarding COVID 19. LPA arrived donned in PPE to include N95, Gown and Gloves. LPA and administrator remained outside the facility.

During the course of complaint investigation (25-AS-20200505094805), California Department of Social Services (CDSS) Community Care Licensing (CCL) learned of additional information regarding an incident reported to CCL on 6/2/20.

On 6/2/20 at 1125 AM, Residential Service Director (RSD) Laura Seely, LVN contacted CCL via phone and reported Resident 1 (R1) had an “assisted fall” on 5/29/20 at 4 PM. RSD reported medical aid wasn’t rendered until 5/30/20 at 2:35 PM when R1 complained of pain at which time EMS was called. RSD reported R1 was subsequently transported and admitted to the Hospital. RSD reported R1 returned to the facility on 6/2/20 with a diagnosis of right femur fracture and was admitted to hospice. On 6/13/20 R1’s death was reported to CCL.

During the course of interviews with facility staff and review of documents provided by the facility, CCL learned, after the “assisted fall,” R1 was put back in bed even after R1 stated her leg felt broken. Staff who were present during the “assisted fall” did not notify a med tech who per the facility fall response procedures, would conduct an evaluation to determine course of actions to include but limited to, summoning emergency medical services. The facility provided corrective action documentation for the staff who failed to report the incident as per facility policy.

Continued on LIC 809-C
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 11/05/2020
NARRATIVE
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A review of medical records provided by the hospital where R1 was treated, revealed R1 was admitted with intractable pain secondary to right hip dislocation and distal right femur fracture found during imaging in the ER (emergency room). Pain was described as constant, severe and non-radiating. It was deemed the benefit from surgery was poor and comfort measures were put into place. X-rays revealed the right hip dislocates “quite a bit.”

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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Personnel Requirements 87411(a)-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
This requirement is not met as evidence by:
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Based on interviews and documents obtained the licensee failed to have competent staff ensure one of one resident needs were met. R1’s fall was not immediately reported per policy and was not rendered medical care for 22.5 hours post fall which resulted in resident being hospitalized. This poses an immediate health and safety risk to residents in care.
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CIvil Penalty assessed in the amount of $500
Type A
11/06/2020
Section Cited

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Enumerated rights; severability. 1569.269(a)(6). To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement is not met as evidenced by:
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Based on interviews and documents obtained the licensee failed to ensure there was competent staff to meet the resident’s needs, which resulted in R1 being hospitalized and in substantial risk of serious injury and sever pain. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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87465(g)-Incidental Medical and Dental Care - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. The requirement is not met as evidenced by:
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Based on interviews and documents obtained the licensee failed to immediately telephone 9-1-1 when a circumstance occurred that posed a threat to the health of one of one resident in care. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4