045002440-7-29-2021-25-AS-RKNT-C5DNGL-20210729102718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:27:37 AM

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:	COUNTRY CREST ASSISTED LIVING		FACILITY NUMBER:	045002440
ADMINISTRATOR:	DAVIS, IRENE		FACILITY TYPE:	740
ADDRESS:	55 CONCORDIA LN		TELEPHONE:	(530) 533-7857
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	150	CENSUS:	DATE:	07/29/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Irene Davis, Executive Director		TIME COMPLETED:	11:00 AM

NARRATIVE

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7/29/2021 10:00 AM, Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to deliver the results of a case management investigation. LPA Knight met with Executive Director Irene Davis. Today's meeting concerns an investigation into an incident report that was received from the facility on 5/06/2021 regarding an incident that occurred at the facility on 5/05/2021.

Allegation: Staff failed to provide adequate supervision to client, resulting in need for medical attention.

On 5/06/2021, Community Care Licensing (CCL) received incident report that stated Resident 1 (R1) was found unresponsive on the outside patio of the Memory Care unit. The report stated that R1 walked out on to the patio and was out there for 27 minutes sitting in the sun before staff found R1. The high temperature reported for Oroville CA on May 5, 2021 was 95 degrees Fahrenheit per The Weather Channel website.

R1 was found by care staff at 12:00 PM in the patio area sitting on a bench with their pants around their ankles. Staff reported that R1 was vomiting and unresponsive, their skin on their arms and legs was red. Staff states when R1 was initially found their temperature was too high for the thermometer to register, and R1’s temperature was 100.4 when they were loaded into the ambulance.

During the course of the investigation LPA interviewed 2 facility administrators, 1 resident, and 4 staff. LPA obtained the following documents: Physician’s Report, Appraisal/Needs and Services Plan, staff list with telephone numbers, Residence and Care Agreement, ER medical record and discharge instructions.

Continued on LIC809-C

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COUNTRY CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
	VISIT DATE: 07/29/2021

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LPA’s review of R1’s Medical Record/Discharge instructions from the local hospital dated 05/07/2021 revealed R1’s primary diagnosis as heat stroke and burned legs. LPA review of R1’s Physician’s Report shows a primary diagnosis of Alzheimer’s Disease with severe dementia. LPA’s review of R1’s Pre-placement Appraisal / Needs and Services plan revealed that R1 is able to walk without any assistance and needs special observation due to confusion, forgetfulness and wandering.

LPA conducted interviews with facility staff and learned the patio door had been propped open because there were painters performing maintenance in the Memory Care unit, and the alarm that normally sounds on the pager system each time the door opens or closes was not functioning because the door was propped open. Patricia Goebin, Executive Director on the date and time that the incident occurred stated There is an alarm on the door that goes to all staff pagers, so every employee knows if a resident goes outside. The patio door was propped open for 1.5 hours that day because the painters were painting the door jambs and they didn’t want the alarms going off. As a result of the doors being propped open staff were not alerted when R1 walked out onto the patio. LPA learned through interviews R1 had walked out onto the patio area unassisted.

Staff interviews revealed that the door that leads to the patio area is normally left propped open in the morning so residents can go in and out. Staff interviews revealed that residents who enter the patio area are observed by staff from inside of the Memory Care Unit.

On the day that LPA Knight was in the facility (6/14/2021) the doors to the patio area of the Memory Care unit were open. LPA Knight observed two residents and one care staff on the patio.

Based on LPA interviews conducted, record review, and observation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. A deficiency is being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22). Appeal rights were provided, and an exit interview conducted, a copy of the report was given to Executive Director, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COUNTRY CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/29/2021 Section Cited	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General 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 was not met as evidenced by:
	8 9 10 11 12 13 14	Based on LPAs interviews of staff and records review it was determined that the licensee did not provide adequate care and supervision to R1 which resulted in R1 eloping to the outside patio area in the Memory Care unit of the facility on a hot day for a prolonged period. This resulted in the resident suffering from heat stroke and burned legs which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Proof of completion shall be sent to the licensing agency by 8/05/2021.
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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 Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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