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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209060
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:20:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2022 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220822160531
FACILITY NAME:PALM GARDEN RETIREMENT HOME & DEMENTIA CAREFACILITY NUMBER:
107209060
ADMINISTRATOR:KOPACZ, CAMALAH S.FACILITY TYPE:
740
ADDRESS:8891 E. HERNDON AVE.TELEPHONE:
(559) 324-1733
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Camalah Kopacz, AdministratorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Resident sustained fracture while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty, obtained and reviewed facility records. It was determined based on the interviews and records reviewed that the above allegation is SUBSTANTIATED.

Per staff interviews, on 08/19/2022, R1’s right arm was fully stuck between the bed and the full bed rail. Staff reported removing R1’s arm from bed rail and observed discoloration the next day.
Per medical records, on 08/21/2022, Resident (R1) was admitted to the hospital due to proximal humerous fracture of right shoulder and R1 had ecchymoses involving the right upper arm extending past the elbow to the upper forearm. Per medical records, R1 had limited range of motion of shoulder and elbow and secondary to severe pain. Per interviews, facility staff delayed seeking emergency medical services until two days after incident and resident sustained a fracture. An Immediate Civil Penalty of $500 is assessed.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 24-AS-20220822160531
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PALM GARDEN RETIREMENT HOME & DEMENTIA CARE
FACILITY NUMBER: 107209060
VISIT DATE: 11/22/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of Appeal Rights were provided to Administrator.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20220822160531
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PALM GARDEN RETIREMENT HOME & DEMENTIA CARE
FACILITY NUMBER: 107209060
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
87464(f)(1)(c)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety...

This requirement is not met as evidenced by:

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Licensee will submit written statement of when she will provide training for staff on observation of residents and when to seek medical attention by 11/23/2022. All training shall be completed and a copy of the training roster with date, signature of attendees, topic of training and name/contact of a trainer shall be submitted by due date of 12/02/2022.

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Based on interviews and records reviewed, R1’s right arm was stuck between bed rails and bed. Staff did not seek medical attention until two days after incident, which poses immediate health, safety or personal rights risk to persons in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3