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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700739
Report Date: 04/14/2023
Date Signed: 04/14/2023 11:38:29 AM


Document Has Been Signed on 04/14/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:PINES, THEFACILITY NUMBER:
312700739
ADMINISTRATOR:HENRY COLEFACILITY TYPE:
740
ADDRESS:500 W RANCHVIEW DRIVETELEPHONE:
(916) 672-5019
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:142CENSUS: 134DATE:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Henry Cole, Executive DirectorTIME COMPLETED:
10:45 AM
NARRATIVE
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On April 14 2023, Licensing Program Analyst DeAnna Williams Lyons arrived to issue a citation. LPA met with Executive Director, Henry Cole, and informed him the reason for the visit. Prior to initiating the visit LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE).
During a complaint investigation at this facility, it was learned that facility staff administered R1 (2) two discontinued medications in conjunction with (2) two newly ordered medication resulting in R1 sustaining hypoglycemia causing R1 to be hospitalized with ICU admission.

The facility did not follow its medication administration process resulting in a medication administration error for R1. Based on the review of the medical records, DSS’ investigative findings, and other miscellaneous documents, the facility failed to follow its medication administration process to ensure there is no medication errors which resulted in serious bodily injury. R1's hypoglycemia, hospitalization, and ICU admission as evidenced by the following clinical relationship to the violation:

The facility failed to ensure staff was following the facility’s medication administration process (1st check). Medication transcription in MAR was done by the MT who received the PCP order for new medication, but facility staff did not discontinue R1's discontinued mediations on R1's MAR.



To continue see 809-C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: PINES, THE
FACILITY NUMBER: 312700739
VISIT DATE: 04/14/2023
NARRATIVE
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The facility failed to ensure 2nd check by MT was done to compare the new medication orders and discontinued medication orders with the Physician order and MAR before administering R1's medications.

Based on records reviewed, the facility failed to follow medication administration process resulting in R1 sustaining a medication error causing hospitalization.

As a result of R1's hospitalization, the violation warrants an immediate civil penalty assessment in the amount of $500. The facility is advised that additional civil penalties are under Departmental review based on Health and Safety code §1569.49 and may be assessed at a later date due to R1 sustaining serious bodily injury while in care.

Citations are issued today based on Title 22 regulations and documented on the attached LIC809-D.

Exit interview and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/14/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: PINES, THE
FACILITY NUMBER: 312700739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited

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87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with medications. This requirement is evident by... Based on LPA's records reviewed and statements recieved during the investigation. The facility failed to ensure and Provide R1 medications.
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Facility to send written plan that will be followed on how they will ensure that residents are receiving the required medication. POC due by 5/15/2023, facility to also provide staff training by 6/1/2023.
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This is an immediate risk to the Health and Safety of Residents in care.
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Civil Penalties were assessed on today's date for the violation. Civil Penty was issued in the amount of $500.00

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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: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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