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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001747
Report Date: 03/07/2023
Date Signed: 03/07/2023 12:07:08 PM

Unsubstantiated


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
02/28/2022 and conducted by Evaluator Melissa Parks
COMPLAINT CONTROL NUMBER: 25-AS-20220228155949
FACILITY NAME:KING ROAD CARE HOMEFACILITY NUMBER:
315001747
ADMINISTRATOR:SHAVLOVSKY, YANAFACILITY TYPE:
740
ADDRESS:5877 KING ROADTELEPHONE:
(916) 660-9947
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Larisa ShitovaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not provide care resulting in resident sustaining pressure injury on both elbows, heel and gluteus

INVESTIGATION FINDINGS:
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LPA Parks arrived on Tuesday March 7, 2023 to conclude a complaint investigation regarding the above allegation. Prior to the visit, LPA completed the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

All staff interviewed acknowledged that R1 moved into the facility with a small redness on her coccyx which was immediately reported to POA. Additionally, all staff acknowledged that she was turned/repositioned every two hours. All staff interviewed denied that there were open wounds on coccyx, heels, and elbows. Staff also acknowledged that R1 was often resistant to care being provided.

Based on incident occuring over twelve months ago, staff acknowledging that resident did have redness on her coccyx upon move-in, there is not sufficent to substantiate or dismiss.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 2
Control Number 25-AS-20220228155949
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: KING ROAD CARE HOME
FACILITY NUMBER: 315001747
VISIT DATE: 03/07/2023
NARRATIVE
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Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. Appeal rights were printed and given along with a copy of this report.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2