092700445-1-4-2024-59-AS-KHOS-CZJPD4-20240116101256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700445
Report Date: 01/04/2024
Date Signed: 01/04/2024 10:57:47 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20231228091353

FACILITY NAME:	PAVILION AT EL DORADO HILLS, THE		FACILITY NUMBER:	092700445
ADMINISTRATOR:	MELISA TIBURCIO		FACILITY TYPE:	740
ADDRESS:	2288 FRANCISCO DR		TELEPHONE:	(916) 542-3452
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	64	CENSUS: 27	DATE:	01/04/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Alison Wall		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Lack of supervision resulted in resident eloping from the facility.
Staff did not provide a safe environment .

INVESTIGATION FINDINGS:

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On 01/04/24 , Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do complaint investigation and to deliver complaint findings into the allegations listed above and met with Executive Director, Alison Wall.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 59-AS-20231228091353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
	VISIT DATE: 01/04/2024

NARRATIVE

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**report continued from 9099.....

Allegation- Lack of supervision resulted in resident eloping from the facility.
Allegation- Staff did not provide a safe environment.

Based on investigation conducted by the Department, which includes interviews and documents obtained regarding the allegation, lack of supervision resulting in client eloping from the facility; it was discovered that on 12/24/23, resident (R1) had left the facility unassisted. This facility serves memory care residents therefore all facility exits are equipped with delay egress exiting. Information obtained indicated R1 was able to exit the facility and walk off facility premises on 12/24/23 at or around 3:40pm. R1 was found by a community member down the street from the facility who brought the resident back. Upon returning to the facility, R1 did not show any injuries resulting from their elopement. The Department reviewed R1’s physician’s report (LIC602) dated 03/13/23 which indicated R1 could not leave the facility unassisted. Based on information obtained and records reviewed, the facility failed to provide proper supervision of R1 resulting in R1 eloping from the facility. The preponderance of evidence standards has been met therefore, the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited on the attached 9099-D page.

Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20231228091353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PAVILION AT EL DORADO HILLS, THE	FACILITY NUMBER: 092700445
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/05/2024 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agrees to submit a plan to the Department on how staff will monitor R1’s exit seeking behavior in an effort to mitigate R1’s attempts to elope from the facility. Additionally, facility shall conduct staff training on residents who have exit seeking and wondering behaviors.
	8 9 10 11 12 13 14	Based on record review, facility staff did not provide care and supervision to R1 resulting in R1 eloping the facility unassisted, on 12/24/23, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Lastly, the facility shall submit a plan on how the facility staff will document any changes in condition in resident in care. POC shall be submitted to the Department by 01/05/24. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

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