312700996-4-20-2022-25-AS-KHOS-CDUHM9-20220426061847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700996
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:19:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2021 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211230161733

FACILITY NAME:	WELLQUEST GRANITE BAY TENANTCO LLC		FACILITY NUMBER:	312700996
ADMINISTRATOR:	MANOMHEHRI, PARI		FACILITY TYPE:	740
ADDRESS:	9747 SIERRA COLLEGE BLVD		TELEPHONE:	(916) 864-9800
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	135	CENSUS: 67	DATE:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Health & Wellness Director- Deziree Thitphaneth		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not follow resident's care plan resulting in multiple UTIs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 04/20/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 12/30/2021. LPA met with Health & Wellness Director, Deziree Thitphaneth, and explained the purpose of the visit. Prior to initiating the visit, 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: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

Throughout the course of the investigation, the Department conducted interviews with a total of six (6) facility staff, three (3) National Home Health Agency staff, and reviewed pertinent documentation relevant to the allegation listed above, such as R1’s Physician’s Report, Medical History Documents, Service Evaluation/Appraisal Needs, Service Plan, Hospice Documents, Facility’s Training Records, Admission Agreement, and Unusual Incident/Injury Reports.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211230161733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WELLQUEST GRANITE BAY TENANTCO LLC	FACILITY NUMBER: 312700996
	VISIT DATE: 04/20/2022

NARRATIVE

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The facility submitted Unusual Incident/Injury reports to CCL for review. The Unusual Incident/Injury report indicate that, on 11/20/2021 at approximately 7:45 PM, R1 was noted to have multiple loose bowel movements and weakness. The facility notified R1’s Responsible Party (RP) and was taken to the ER for further evaluation for UTI and positive for C-Diff. On 11/27/2021, R1 returned to the community with new orders and care plan was updated as needed. On 12/10/2021, R1 was not feeling well and notified the facility. R1 was transferred to the ER for further evaluation. R1 was diagnosed with UTI and C-Diff.

The Department reviewed R1’s past and current medical records. Medical records document R1’s past medical history of indwelling Foley catheter with recurrent UTI. R1’s admission agreement indicated R1 moved into the facility on 08/12/2021. On 01/19/2021, R1 was treated for UTI. Interview statement received from R1’s RP indicated that R1 has had UTIs throughout the year; however, not back-to-back and one after another in a short period of time.

The Department reviewed R1's service plan which indicated R1 needed assistance with grooming, toileting, medication management, bathing, and dressing. R1 received Home Health for Foley Catheter care. In-service training for Foley Catheter care was conducted on August 2021 and November 2021. According to service plan, staff is to assist R1 with catheter care and emptying catheter every shift. Assist with changing R1's catheter (only) from day bag to night bag as needed (3 times per day, every day). It was discovered through interviews with six (6) facility staff that care staff had followed service plan instructions.

This agency has investigated the above listed allegation. Although R1 was diagnosed with a UTI on multiple occasions while residing at the facility, the department was unable to determine if it was due to facility neglect. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED.

An exit interview conducted.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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