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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002891
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:40:29 PM


Document Has Been Signed on 06/10/2024 02:40 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:FOOTHILL COTTAGEFACILITY NUMBER:
045002891
ADMINISTRATOR:ABEJO, KRISTINEFACILITY TYPE:
740
ADDRESS:3064 CEANOTHUS AVENUETELEPHONE:
(530) 809-0418
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:6CENSUS: DATE:
06/10/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Administrator- Kristine Abejo TIME COMPLETED:
03:00 PM
NARRATIVE
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On 06/10/2024 LPA Jaynae Boyles and LPM Lauren Crocker held an office visit to meet with Licensee/Administrator, Kathrine Abejo to discuss concerns regarding an incident report received from the licensee. The report received on April 26, 2024 outlines an incident where a resident (R1) sustained a fall in the early morning hours on 4/24/24, followed by a detailed timeline showing the facility failed to seek medical attention in a timely manner.

Details in the report include the following information: the fall happened at 4am on 4/24/24, followed by the resident being sent to day program by facility staff at 8:30 am. At 9:50 am that same morning, the day program sent the resident home stating R1 “is not feeling well” and “cant get up from her wheelchair to use the bathroom.” R1 was returned to the facility at 10:30 am. R1 had soiled their pants twice while at day program due to inability to transfer to the toilet. At 6:00 pm the same day facility staff contacted the facility Administrator, Kristine Abejo, to inform her R1’s left leg was swollen. According to the incident report, Abejo advised staff to put a leg brace on, which R1 used last year in March when R1 had a broken ankle, “until tomorrow morning because it hurts every time she moves.”

The following day, 4/25/24 at 9:40 am, almost 29 hours after the incident occurred, R1 was taken to the medical clinic where they took x-rays. The doctor’s orders were for the resident to go to the emergency room due to x-rays showing that the tibia and fibula were fractured. At 1:00 pm at the emergency room and the administrator was informed that the resident “will need a surgery tomorrow by placing a titanium rod to straight the bone. She will stay at the hospital for 3-4 days.”

As a result of the resident’s injury and the facility’s failure to seek medical attention in a timely manner, the violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.


Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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Document Has Been Signed on 06/10/2024 02:40 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/10/2024
Section Cited
CCR
87465(g)

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Incidental Medical and Dental Care (g) 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 including, but not limited to, an apparent life-threatening medical crisis …
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Licensee will submit a copy of the emergency response policy as well as a plan to provide training with all employees prior to their work in the home.
The POC is due by 06/17/24.
Policy, training plan and 7 day schedule to be submitted.

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This requirement has not been met as evidenced by the incident report submitted to the Department which describes the events of the incident and articulates that R1 did not receive medical treatment for over 24 hours for an fall resulting in injury that they had at the facility.
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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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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