097004177-11-18-2021-25-AS-LMUZ-C9H3QM-20211207172716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097004177
Report Date: 11/18/2021
Date Signed: 11/18/2021 12:56:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 25-AS-20210513145946

FACILITY NAME:	PONTE PALMERO		FACILITY NUMBER:	097004177
ADMINISTRATOR:	KASNER, GREGORY		FACILITY TYPE:	740
ADDRESS:	3083 PONTE MORINO DRIVE		TELEPHONE:	(530) 677-9100
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	250	CENSUS: 175	DATE:	11/18/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Gregory Kasner		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained severe dehydration and a UTI due to lack of care and supervision.

Staff did not ensure changes in resident's condition were reported to a physician in a timely manner.

INVESTIGATION FINDINGS:

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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Gregory Kasner. Findings are based on IB Report # ND2521-05110

Allegation: Resident sustained severe dehydration and a UTI due to lack of care and supervision.
On 1/26/21, R1 was admitted to Mercy Folsom for severe dehydration and a urinary tract infection. At the time of hospitalization, R1 was positive for Covid-19 and was quarantined to her room, being monitored by a single staff member. According to witnesses who were aware of R1's condition, R1 had not eaten and drank little to no fluid/water for approximately 2 - 3 days prior to being hospitalized. Documents reviewed indicate that R1 did not have fluids or food for approximately 3 days from 1/23/21 through 1/25/21. Medical records from Mercy Hospital of Folsom indicated that at the time of admission, R1 was dehydrated and had an abnormal urinalysis.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210513145946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PONTE PALMERO	FACILITY NUMBER: 097004177
	VISIT DATE: 11/18/2021

NARRATIVE

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Allegation: Staff did not ensure changes in resident's condition were reported to a physician in a timely manner.
On 1/26/21, R1 was admitted to Mercy Folsom for severe dehydration and a urinary tract infection. At the time of hospitalization, Patricia was positive for Covid-19 and was quarantined to her room and was being monitored by a single staff member. R1 had not eaten and drank little to no fluid/water for approximately 2 - 3 days prior to being hospitalized. Review of documents indicate that R1 did not have fluids or food for approximately 3 days from 1/23/21 through 1/25/21. Facility did not report R1's condition to medical personnel in a timely manner. Witness was asked if R1's medical attention should have been sought sooner, witness replied, "yeah, maybe a day before."

As a result of this investigation, LPA finds the allegations that resident sustained severe dehydration and a UTI due to lack of care and supervision, staff did not ensure changes in resident's condition were reported to a physician in a timely manner to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210513145946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PONTE PALMERO	FACILITY NUMBER: 097004177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 11/18/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411-Personnel Requirements-General- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of	1 2 3 4 5 6 7	Facility shall submit a written plan to prevent this type of harm from occurring in the future. Facility shall address appropriate staffing levels and services necessary to meet resident's needs. This shall be done within 3 days. Facility shall forward documents to LPA to clear this deficiency.
	8 9 10 11 12 13 14	personal assistance and care as required... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on medical records and witness statements, licensee did not have adequate staffing available to provide care and supervision to residents. This is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type A 11/17/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466-Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When	1 2 3 4 5 6 7	Facility shall submit a written plan to prevent this type of harm from occurring in the future. Facility shall address appropriate staffing levels and address observation of residents, in compliance with this section, to provide appropriate and necessary assistance when
	8 9 10 11 12 13 14	changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on witness interviews and medical records, licensee did not observe that a resident became dehydrated and required hospitalization Facility is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	required. This shall be done within 3 days. Facility shall forward documents to LPA to clear this deficiency.

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: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC9099 (FAS) - (06/04)

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