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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001839
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:13:08 PM


Document Has Been Signed on 05/17/2022 03:13 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:IRIS CARE HOMEFACILITY NUMBER:
045001839
ADMINISTRATOR:ANGHELUTA, NICOLETAFACILITY TYPE:
740
ADDRESS:4117 LOWER WYANDOTTE RD.TELEPHONE:
(530) 534-7996
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:8CENSUS: 8DATE:
05/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicoleta Angheluta, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 05/17/2022, at 1130 am, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management visit and met with Nicoleta Angheluta, Administrator. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Manager and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Nicoleta Angheluta, Administrator.

During an investigation of a recent complaint the Department conducted interviews with staff, residents and reviewed records. It was determined that the facility Failed to seek timely medical attention for a resident in care.

Neglect/Lack of Care: Licensee Nicoleta Angheluta failed to seek timely medical attention after observing a large chest hematoma on R1.

Conclusion: Nicoleta admitted that after R1 sustained a large area of discoloration on her chest following a COVID-19 booster vaccination on 02/23/2022, she did not seek medical attention for R1. Nicoleta described the chest hematoma as a large purple discoloration from R1's armpit to the middle of her chest. Nicoleta said she felt guilty for not seeking immediate medical attention. She said that she failed to seek medical attention because R1 did not complain of pain or have any significant changes in condition other than the purple discoloration. Staff 1 S1 observed R1 to have the chest hematoma on 02/23/2022 and corroborated that medical attention was not sought for it.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.


Plan of correction (POC) were discussed. Appeal rights were provided and exit interview conducted
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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Document Has Been Signed on 05/17/2022 03:13 PM - It Cannot Be Edited

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 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: IRIS CARE HOME
FACILITY NUMBER: 045001839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited

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87465 Incidental Medical Needs (a)(1) - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Based upon department interviews and records review, the licensee failed to arrange medical care in for R1 while in care. This poses an immediate health and safety risk to clients in care.
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An outline of the training given and a roster w/ signatures will be faxed to CCL no later than 05/31/2022.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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