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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001487
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:38:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220811151722
FACILITY NAME:JABEZ HOMESTEADFACILITY NUMBER:
315001487
ADMINISTRATOR:SAMANTHA CORKERFACILITY TYPE:
740
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 888-8620
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:0CENSUS: 0DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility Neglect resulted in resident’s death:
Facility staff failed to meet residents' needs.
Facility staff did not seek resident timely medical attention.
Facility did not notify family of change in resident's condition.
Facility refused to allow resident to have medical visitations while in care.
Facility retained a resident requiring a higher level of care.
INVESTIGATION FINDINGS:
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On 10/01/2020, the licensee of this home initiated a closure with the Department. On 08/11/2022, the department received a complaint alleging the allegations listed above. Although this facility is closed, there is no time limitation in statute that prevents the Department from investigation allegations that occurred at a facility at the time licensure. Allegation: Facility Neglect resulted in resident’s death: the Department has interviewed witnesses and staff and reviewed medical records. The Department learned that the death certificate of resident R1 lists sepsis with onset one week, decubitis ulcer with onset of months, and ishemic cerebral artery stroke with onset of years as cause of death. Home health records indicate that facility Jabez caregivers verbalized understanding of pressure injury care by home health nurses on 7/28/20, 8/7/20, and 8/12/20. However, after six days (8/12/20 to 8/18/20) under care of Jabez caregivers, R1’s injuries worsened, requiring immediate medical care intervention by a home health nurse who called 911. Home Health nurse confirmed that Jabez staff had denied entry to her due to a resident being exposed to COVID-19 and wound care was suspended from 8/12/20 to 8/18/20. Caregivers denied seeing that the pressure injury had worsened despite caring for R1 daily. The allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
VISIT DATE: 03/10/2023
NARRATIVE
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Allegation: Facility staff failed to meet residents' needs. During the course of the investigation, interviews with prior staff were conducted as well as records reviewed. Interviews indicated facility staff left R1 in soiled briefs for extended periods of time. In addition, R1 required a two person assist for bathing and transferring. Staff stated they had a difficult time lifting and transferring R1 and also stated the facility did not have a Hoyer lift to assist staff with transferring and lifting R1. Based on staff statements, the facility did not meet the needs of R1 who required assistance with toileting, bathing and incontinence care, therefore allegation is Substantiated. The “preponderance of the evidence” standard has been met.

Allegation: Facility staff did not seek resident timely medical attention.
Home Health Care records indicated facility staff were instructed and verbalized
understanding for R1’s pressure injury care on 7/28/2020, 8/7/2020 and 8/12/2020 by home health nurse. Over a six-day period (8/12/2020 - 8/18/2020), facility staff failed to seek medical care intervention until a home health nurse came to the facility on 8/18/2020. During the nurse visit to R1 on 8/18/2020, the nurse examined and intervened in R1's care. Interviews and documentation indicated Home Health instructed Administrator on wound care (cleanse friction and shear areas to bilateral buttocks, apply moisture barrier cream to peri-wound, and apply triad to open wounds, leave open to air, turn and position every two hours, float heels and protect pressure points) which Administrator verbalized understanding. Home health indicated R1 was found to have a sacral foam
dressing in place with contact layers placed on wounds. Administrator denied knowledge about the deterioration of R1’s pressure injuries. Facility staff did not contact 911, Home Health or R1's primary care physician regarding the deterioration of R1’s pressure injuries despite being provided with instructions to do so.
At the time of the Home Health Care nurses visit, Home health nurse felt R1’s pressure wounds required immediate medical attention and called to 911. Since R1’s was documented as requiring incontinent care and needed to be repositioned every two hours, facility staff should have observed R1’s pressure wounds worsening and contacted Home Health Care staff as instructed. Facility staff did not seek timely medical attention for R1 therefore, Substantiated. The “preponderance of the evidence” standard has been met.
Allegation: Facility did not notify family of change in resident's condition.
Home Health Care records indicated facility staff were instructed and verbalized
understanding for R1’s pressure injury care on 7/28/2020, 8/7/2020 and 8/12/2020 by home health nurse. A visit from home health on 08/18/2020 identified R1’s pressure wounds to have deteriorated to a point that immediate medical attention was needed.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
VISIT DATE: 03/10/2023
NARRATIVE
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Facility staff did not contact 911, Home Health or R1's primary care physician regarding the deterioration of R1’s pressure injuries despite being provided with instructions to do so. The facility did not notify R1’s responsible party and/or primary care physician regarding R1’s change in condition therefore, Substantiated. The “preponderance of the evidence” standard has been met.

Allegation: Facility refused to allow resident to have medical visitations while in care.
Based on Provider Information Notice (PIN) 20-07-ASC Observed dated March 13, 2020, page seven; “The licensee shall not restrict CDSS, CDPH, local health department officials, and healthcare providers, Ombudsman, and essential government authority from entering or conducting investigations at the facility. Additional exceptions to visitor restrictions include end-of-life situations”. The licensee denied home health entry into the facility citing COVID-19 visitation precautions. Due to the licensee denying home health entry, R1 was not afforded services needed for care. The facility violated the department’s visitation guidance therefore allegation Substantiated. The “preponderance of the evidence” standard has been met.

Allegation: Facility retained a resident requiring a higher level of care.
Based on interviews conducted and records reviewed, R1 was seen in the emergency room on 8/18/2020. Wound Assessment at the hospital indicated R1 sustained (2) two wounds; Bilateral buttocks, Pressure Ulcer/Injury and Bilateral heels, Pressure Ulcer/Injury that were identified as unstageable. In addition, facility staff interviews indicated staff felt R1 needed a high level of care than what the facility was able to provide. The facility retained a resident with a prohibited health condition without requesting an exception and facility staff indicated R1 needed a level of care higher than the facility was able to provide. Therefore the allegation above is Substantiated. The “preponderance of the evidence” standard has been met.

The Department has exhausted all efforts to locate and contact the licensee by phone or email. On 3/10/2023 a copy of this report was sent certified mail to Kim Cavender. Appeal Rights provided to Kim Cavender. The Department is requesting the licensee to return this report back to the Department with signatures acknowledging receipt of the report and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
87464(f)(1)
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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).
This requirement was not met as evidenced by: The facility failed to ensure that the resident’s medical needs
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Although facility is cited for this violation, no POC is required as this facility is no longer in operation.

* An immediate civil penalty is issued in the amount of $ 500.00.
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were met in that she developed unstageable decubitis ulcers while under the care of the facility; the facility failed to seek medical care for the condition between 8/12/2020 and 8/18/2020.
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Type A
03/13/2023
Section Cited
CCR
87464(f)(4)
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Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed
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Although facility is cited for this violation, no POC is required as this facility is no longer in operation.
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medications, as specified in Section 87608, Postural Supports. This regulation was not met as evidenced by: the resident was found in soiled briefs for extended periods of time.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not
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Although facility is cited for this violation, no POC is required as this facility is no longer in operation.
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met as evidenced by: during the time between 8/12/2020 and 8/18/2020 wound care nurse for resident R1 was not allowed into the home by facility staff due to a COVID exposure in the home. During that time, R1's decubitis wounds reached the point of being considered "unstageable.” The home failed to seek medical attention or emergency medical services until the wound care nurse returned on 8/18/2020 and contacted 911.
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Type A
03/13/2023
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of
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Although facility is cited for this violation, no POC is required as this facility is no longer in operation.
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mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: When R1’s wounds deteriorated to the point of requiring immediate medical attention, the facility did not notify the primary physician or Responsible Party.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
87468.1(a)(16)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement was not met as evidenced by: Resident R1 was not allowed to have a wound care nurse
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Although facility is cited for this violation, no POC is required as this facility is no longer in operation.
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come to the facility to provide care from 8/12/2020 until 8/18/2020 citing COVID-19 exposure in the facility.
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Type A
03/13/2023
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced
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Although facility is cited for this violation, no plan of correction is required as this facility is no longer in operation.
An immediate civil penalty in the amount of $500.00 is to be assessed for R1 sustaining a serious bodily injury while in care at this facility. Additionally, the vilaton warrants a
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by: On 8/18/2020 resident R1 was taken to the Emergency Room and wound assessment found R1 had wounds that were unstageable
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civil penalty assessment based on Health and Safety Code § 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.
The Department has exhausted all efforts to locate and contact the licensee by phone or email. On 3/10/2023 a copy of this report was sent certified mail to Kim Cavender. Appeal Rights provided to Kim Cavender. The Department is requesting the licensee to return this report back to the Department with signatures acknowledging receipt of the report and appeal rights provided.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 25-AS-20220811151722

FACILITY NAME:JABEZ HOMESTEADFACILITY NUMBER:
315001487
ADMINISTRATOR:SAMANTHA CORKERFACILITY TYPE:
740
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 888-8620
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:0CENSUS: 0DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff was not adequately trained.
Licensee did not properly manage facility funds.
Resident sustained an unwitnessed fall resulting in a fracture while in care.
Facility did not prevent resident from sustaining pressure injuries while in care.
INVESTIGATION FINDINGS:
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Allegation: Facility staff was not adequately trained. Based on interviews with staff, staff indicated that training was conducted at the time of hire however specific training topics were not indicated. Although facility staff were given new hire training, training specific topics and training records were not available therefore the above allegation is deemed as unsubstantiated.

Allegation: Licensee did not properly manage facility funds. During the course of the investigation, no documents, interviews or information was obtained to determine if the licensee did not properly manage facility funds. The department was unable to obtain documentation regarding facility funds therefore the above allegation is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Resident sustained an unwitnessed fall resulting in a fracture while in care.
Medical records reflect that R1 suffered an unwitnessed fall causing an injury to
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20220811151722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JABEZ HOMESTEAD
FACILITY NUMBER: 315001487
VISIT DATE: 03/10/2023
NARRATIVE
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right hip that required surgery to correct; however medical staff did not note that neglect or lack of care was the cause of R1’s injury. Staff stated that a pole was placed in R1's room to assist with mobility. Additionally, R1’s bed was equipped with half bed rails. Based records reviewed and interviews conducted this allegation is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility did not prevent resident from sustaining pressure injuries while in care.
Home Health Care records identified R1 did not have pressure injuries at the onset of care. However, later developed pressure injuries while in their care and noted pressure injury wound care was added to R1’s treatment plan. Although R1 developed pressure injuries while in care, no information obtained during the investigation indicated the facility could have prevented R1 from sustaining pressure wounds therefore the allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8