315001719-6-14-2021-27-AS-KMKY-C3ZTSL-20210615145917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315001719
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:15:39 PM

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
10/09/2020 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 27-AS-20201009102313

FACILITY NAME:	NEWPORT HOME		FACILITY NUMBER:	315001719
ADMINISTRATOR:	KIM, AUSTIN		FACILITY TYPE:	740
ADDRESS:	1123 NEWPORT WAY		TELEPHONE:	(916) 784-0111
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 3	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Staff, Romelyn Ninobla		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Lack of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived unannounced at the facility on 06/14/2021 to deliver complaint findings for allegation: Lack of supervision. Staff, Rojel Ninobla answered the door and made Administrator aware of LPA's presence. LPA spoke with Administrator over the phone and explained the purpose of the visit. Administrator stated he was unavailable to come to the facility, therefore LPA read the findings to Administrator. Administrator had staff, Romelyn Ninobla sign the document.

Community Care Licensing (CCL) continued investigation of complaint on 05/20/2021 due to delays caused by the current pandemic. CCL conducted interviews and reviewed documentation relevant to the allegation listed above.

Results are as follows:

***Continuation on LIC9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 27-AS-20201009102313

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: NEWPORT HOME	FACILITY NUMBER: 315001719
	VISIT DATE: 06/14/2021

NARRATIVE

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On 09/25/2020 resident (R1) eloped the facility premises between 2am and 7am. R1 was found that morning by Roseville Police Department who contacted the facility to notify them of R1's whereabouts. R1 was transported to Sutter hospital in Roseville. No injuries were reported. Based on interviews with facility staff, R1 had been agitated since they moved in and was having trouble sleeping. Records do not show a re-appraisal was performed and R1's care plan remained the same. On 09/25/2020 Staff stated R1 was "agitated" again and was stating they "wanted to go home." Staff (S1) told R1 to go back to sleep. At 7am, S1 went to check on R1, however R1 was not in their room. S1 stated there are no wake staff on duty at night and the alarm on R1's exit room door "did not go off" on the day of incident reported. LPA attempted to gather further information from the Police Department, R1's family members and Sutter Hospital, however no further evidence could be provided.

Based on the information above, LPA finds the allegation to be SUBSTANTIATED, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

As a result of today's visit, deficiencies are being cited on LIC9099-D per Title 22 rules and regulations, Division 6.

An exit interview was conducted and a copy of this report, and appeal rights provided.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201009102313

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: NEWPORT HOME	FACILITY NUMBER: 315001719
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2021 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.	1 2 3 4 5 6 7	The Licensee understands the importance of updating resident's appraisals as necessary to note signicant changes and to keep the appraisal accurate. Licensee agrees to send to CCL a letter of understanding by the POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: the licensee did not update R1's appraisal after noticing R1's change in condition. This posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
Type A 06/15/2021 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: facility did not ensure R1's exit door alarm was active.	1 2 3 4 5 6 7	The Licensee understands all auditory devices or other staff alert features to monitor exits must be in working order at all times. Licensee agrees to maintain and make sure alert devices are active at all times. Plan of correction to be cleared by visit.
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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: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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