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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700311
Report Date: 04/28/2021
Date Signed: 04/28/2021 11:46:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ABOUTLIFE CARE FACILITYFACILITY NUMBER:
312700311
ADMINISTRATOR:SCUTARU, ELIZAVETAFACILITY TYPE:
740
ADDRESS:2705 LUPINE CTTELEPHONE:
(916) 844-8540
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 6DATE:
04/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tatiana Danu, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 04/28/2021 at 10:00 AM Licensing Program Analyst (LPA) McCrory conducted an unannounced visit to conduct an Investigation/ Case Management visit regarding an incident that occurred at the facility on 04/16/2021. Prior to visit, LPA conducted a self-assessment and had no COVID-19 related symptoms. During visit, LPA wore a mask for COVID-19 precautionary measures. Upon arrival, LPA met with Tatiana Danu, Administrator.

LPA reviewed the following documentation at the facility: Needs and Services Plan, Hospital Discharge paperwork, Staff Training, Personnel Report (LIC 500), Resident/Client File(s).

According to self reported incident report provided by the facility to the Department, on 04/16/2021 Resident (R1) left facility grounds unassisted. It is notated that R1 has a diagnosis of Alzheimer and based on medical assessment is unable to leave the facility unassisted. According to interviews, once staff realized R1 was missing from the facility at 7:49 AM staff searched backyard and nearby streets but could not locate R1. Facility contacted local law enforcement to report R1’s elopement. At 8:20 AM, local law enforcement reported to the facility. R1 was found by a pedestrian lying on the ground approximately 1.4 miles away from the facility. R1 appeared to be injured and the pedestrian called the ambulance. R1 was transported to a local hospital where R1 was treated for a head injury with lacerations that required sutures. Law enforcement was contacted regarding R1's location at the hospital and then the facility was notified of R1’s whereabouts.

Based on the investigation findings, the facility did not provide proper care and supervision to R1 resulting in R1 eloping from the facility and sustaining injuries.

Deficiencies are being cited today from CCR §87468.2(a)(4) and listed on the attached LIC809D.
In addition, an immediate civil penalty is being assessed today in the amount of $500 (five hundred dollars).

Civil penalties for violations resulting in serious bodily injury is/are pending a departmental review at this time and additional administrative actions may occur.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ABOUTLIFE CARE FACILITY
FACILITY NUMBER: 312700311
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2021
Section Cited

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In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in
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numbers, qualifications, and competency to meet their needs.
This regulation is not met as evidenced by LPA observation and case management investigation.
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*** this page was amended on 05/11/2021***
The Deficieny Type was changed from Type B to Type A due to the presence of an immediate or substantial threat to the physical health, mental health or safety of the client of a community care 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021
LIC809 (FAS) - (06/04)
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