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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097005554
Report Date: 02/26/2021
Date Signed: 04/30/2021 01:01:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201005113016
FACILITY NAME:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 2DATE:
02/26/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Priya Lal, AdminitratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility Failed to meet resident's care needs
INVESTIGATION FINDINGS:
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On February 26, 2021 at 1:30pm Licensing Program Analyst (LPA) DeAnna Williams-Lyons delivering complaint findings. Due to the Pandemic, LPA met with Priya Lal the administrator by telephone. Community Care Licensing (CCL) received a complaint allegation stating the facility failed to meet resident’s care needs.
Regarding this allegation, LPA reviewed staff schedules, incident reports, medication logs, and charting notes. LPA interviewed 5 staff, 2 residents and a witness.

Based on observation and interviews LPA could neither confirm nor deny this allegation occurred.and finds the allegation to be UNSUBSTANTIATED - This means although the allegation may have happenor is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.,

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201005113016

FACILITY NAME:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 2DATE:
02/26/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Priya Lal, AdminitratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are not properly trained
Facility does not provide a safe environment for residents
Facility failed to report incident to licensing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) DeAnna Williams-Lyons delivering complaint findings on 2/26/2021. LPA met with Priya Lal the administrator via telephone, due to the Pandemic. Community Care Licensing (CCL) received a complaint allegation stating the Facility staff not properly trained, facility failed to provide a safe environment for residents and Facility failed to report an incident to Licensing.

LPA reviewed employee training records for five staff. Three of the five staff have incomplete training. When LPA interviewed staff, they agreed more training is needed. In addition, staff are not properly trained in handling and dispensing the medications to the residents. In an interview with the administrator on 1/29/21, she stated when she took over as the administrator of the facility in August, 2020, she noticed the staff was lacking the required training and enrolled the staff in the necessary courses to get them up to date on the training requirements. When the allegation was made, the requirements of the Health & Safety Code 1569.625 were not meet.


To continue see 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20201005113016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EL DORADO HILLS SENIOR CARE
FACILITY NUMBER: 097005554
VISIT DATE: 02/26/2021
NARRATIVE
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Continue From 9099-A...

Based on LPAs observations and interviews which were conducted and recorded, the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. This poses an immediate Health and Safety risk to clients/residents in care.

LPA interviewed a Witness on 1/30/2021, regarding the facility not providing a safe environment. The witness saw her patient’s family member fall in the driveway of the facility. The witness stated the pavement was uneven. The family member’s ankle became swollen and painful to ambulate. The witness advised the staff that was working, of the incident. The family member called the director and advised of the fall. Family member made a medical appointment for the next day. The witness made contact with the family member regarding the outcome of the medical appointment. Family member has a displaced fracture through the base of the 5th metatarsal and had another appointment with an orthopedic. The family member had called the Director and asked that her medical bills be paid. The director gave her the number of the owner of the facility. LPA interviewed the staff that worked and confirmed that the incident occurred.

Based on the witness and staff interviews that were conducted, there is a preponderance of evidence supports the allegation. Therefore, this allegation is SUBSTANTIATED.

Regarding the allegation Facility failed to report an incident to Licensing, LPA reviewed facility incident reports and conducted interviews. Upon reviewing facility documentation, no incident report was submitted to CCL regarding a witnessed fall with injury. During a staff interview, it was stated they did not realize a report had not been submitted to LICENSING.

Based on LPAs observations and interviews which were conducted and recorded, the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. Deficiencies cited on 809-D, per Title 22 Regulations, Division 6. Appeals rights discussed and printed.

Exit interview conducted and copy of this report was given to Priya.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201005113016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EL DORADO HILLS SENIOR CARE
FACILITY NUMBER: 097005554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2021
Section Cited
CCR
87468(a)(2)
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87468(a)(2)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This was not met by uneven pavement in the
driveway and causing a fall with injury.
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Licensee will submit a plan to the department on how staff will ensure resident safety at all times. Licensee shall send POC to licensing by 03/26/2021.
Type B
02/26/2021
Section Cited
CCR
87412
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87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
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The licensee shall have all necessary training completed. The licensee shall provide LPA with a copy of all staff's first aid certifications and verification of twenty hours of training for all staff via email by 3-26-2021.
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LPA observed staff did not have required training on file. This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
02/26/2021
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D)
Reporting Requirements.
The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident.
Based on no incident report submitted .
on fall with injury
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The Administrator agrees to following:
The Administrator shall submit a statement of understanding to Title 22 regulation, Section 87211. POC shall be submitted by, 326/21
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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4