<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:47:02 PM


Document Has Been Signed on 12/06/2023 01:47 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:COUNTRY CREST ASSISTED LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR:DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:150CENSUS: 65DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Irene Davis - Executive DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
12/06/2023 12:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing via death report. LPA made the visit to attain additional detail related to the incident and gain insight into the sequence of events.

The death report stated that Resident 1 (R1) was sent to skilled nursing after a hospital stay at Oroville Hospital due to a fall with head trauma and possible syncope. R1 was in the process of being admitted to hospice on the date of their expiration with intent to return to Pacifica Legacies Community. On 11/13/2023 R1 was found without a pulse and not breathing. R1 was DNR and was allowed a natural death at the skilled nursing facility.

During the course of the investigation, it was learned that R1 had moved into the facility on 10/04/2023. On 10/09/23 care staff found R1 in the entry way of the memory care unit, staff noted a skin tear on R1’s left upper arm, staff also noticed some edema on R1’s right heal. 911 was called and R1 was transported to Oroville Hospital to be examined and treated. R1 returned to the facility the same day with diagnosis of left heel pressure blister, was sent home with antibiotics. On 10/10/23 staff found R1 on the floor in the dining room, bleeding from a cut above their right eye due to an unwitnessed fall. R1 had a dementia diagnosis and they had spontaneously tried to get up out of their wheelchair, even though they could not hold their own weight unless being transferred. R1 had lost the ability to maintain the sequence of standing and walking. R1 was sitting in the common area watching Tv with the other residents. Staff walked away for a minute around the corner and came back and R1 was on the floor. 911 was called and transported R1 to Oroville Hospital to be evaluated. R1 was treated for the head wound receiving stitches to the laceration and IV antibiotics for the ulcer on their heal. R1 was kept in hospital for observation and for IV antibiotic treatment for edema. Resident tested positive for Covid 19 while at Oroville Hospital during their stay. R1 was sent to skilled nursing for physical therapy due to falls. R1 was at the skilled nursing facility for 3 to 4 weeks and passed away at the skilled nursing facility on 11/13/2023.

No deficiencies were cited as a result of today's visit.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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 1