312700311-11-22-2021-25-AS-BMII-C8ZPRU-20211122103319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700311
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:33:29 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 FACILITY		FACILITY NUMBER:	312700311
ADMINISTRATOR:	SCUTARU, ELIZAVETA		FACILITY TYPE:	740
ADDRESS:	2705 LUPINE CT		TELEPHONE:	(916) 844-8540
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	6	CENSUS: 6	DATE:	11/22/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tatiana Danu, Administrator		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 22, 2021, Licensing Program Analyst (LPA) Bethany Mirlohi and Jacob Williams met with Administrator of facility Aboutlife Care Facility, Tatiana Danu, at approximately 10 AM. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility. This report is for a case management visit to follow up on a deficiency cited at the facility regarding an incident that occurred on April 16, 2021, in which a resident needing assistance to leave the facility, left the facility grounds unassisted resulting in the resident sustaining an injury. On April 28, 2021, at 10:00 a.m., the Community Care Licensing Division (CCLD) conducted a case management visit. LPA Jasmine McCrory reviewed documentation at the facility, including resident R1’s needs and services plan, hospital discharge paperwork, staff training, Personnel Report (LIC 500), and resident files. Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
	VISIT DATE: 11/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

According to incident report provided to the Department on April 19, 2021, R1 left the facility grounds unassisted on April 16, 2021. It is notated that R1 has a diagnosis of Alzheimer’s 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 a.m., staff searched the backyard and nearby streets but could not locate R1. Facility contacted local law enforcement to report R1’s elopement. At 8:20 a.m., local law enforcement reported to the facility that 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 for an emergency ambulance. R1 was transported to a local hospital where R1 was treated for an injury with lacerations that required sutures. R1 was admitted to the hospital for injuries on April 16, 2021, and was discharged back to the facility on April 17, 2021.

Based on the investigation findings, the facility did not provide proper care and supervision to R1 in accordance with R1s’ needs and service plan, resulting in R1 sustaining injuries while eloping from the facility.

A deficiency was cited for violating California Code of Regulations, Title 22 Division 6, Chapter 8, regulation § 87468.2(a)(4) - In addition to the rights listed in § 87468.1, Personal Rights of Residents in All Facilities, resident in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

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
	VISIT DATE: 11/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At the time of the complaint visit, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

Today, 11/22/21, the Department will be issuing a civil penalty per Health and Safety Code 1569.49, in the amount of $9,500 ($10,000.00 less $500.00 previously issued on April 28, 2021).

An exit interview was conducted and a copy of the report of the report was issued. Appeal rights provided. Tatiana Danu signature on this report acknowledges receipt of these rights, found on page 2 of the LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3