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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001747
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:48:50 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230602092816
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: 6DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Larisa ShitovaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Medication mismanagement
INVESTIGATION FINDINGS:
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LPA Parks arrived on Monday November 27, 2023, to conclude a complaint investigation regarding the above allegation.

LPA met with Administrator Larisa and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed R1, Facility staff, residents, and R1’s nurse practitioner. LPA conducted a document review of R1 and R2’s file. Additionally, LPA reviewed documents obtained from R1’s pain management clinic. The result of the investigation is as follows:

R1 moved into the facility in February 2022. R1’s physicians report dated 2/23/2022 states that R1 has mild cognitive impairment. The physicians report also states that R1 cannot manage their own medication, specifically administer, perform, and store the medications.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 5
Control Number 59-AS-20230602092816
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KING ROAD CARE HOME
FACILITY NUMBER: 315001747
VISIT DATE: 11/27/2023
NARRATIVE
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Upon review of R1’s documents from the pain management clinic, LPA learned that R1’s cheek swab tested as ‘inconclusive’ as to the presence of opioids. R1’s documents reveal the presence of opioids upon further testing. Additionally, notes from the treating physician stated that R1 vocalized that they experienced pain relief from the prescribed opioids.

LPA reviewed emails between the Administrator and R1’s POA which took place between April 16 and April 28, 2023. In these emails, both the POA and Administrator acknowledge that R1 was able to keep their evening scheduled pills in their room and take at their leisure. Additionally, the emails reveal that staff observed R1 to be storing some pills (10 pills) in their room to take at a future date. All interviews acknowledge that staff manage medication for all residents at the facility.

Additionally, when LPA was conducting the initial 10-day complaint visit at the facility, all residents were interviewed regarding the allegations and their time at the facility. While interviewing R3, LPA noticed that their pills were in a cup beside their recliner in their apartment. There was no staff present in the room with R3.

Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2023 and conducted by Evaluator Melissa Parks
COMPLAINT CONTROL NUMBER: 59-AS-20230602092816

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: 6DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Larisa ShitovaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff threw object at a resident
INVESTIGATION FINDINGS:
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LPA Parks arrived on Monday November 27, 2023, to conclude a complaint investigation regarding the above allegation.

LPA met with Administrator Larisa and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed R1, Facility staff, residents. LPA conducted a document review of R1 and R2’s file. The result of the investigation is as follows:

R2’s physicians report stated that their primary diagnosis is Dementia without behavioral disturbances. LPA interviewed all current residents which did not reveal any instances of mistreatment. No interviews revealed that residents were afraid or intimidated of staff. LPA reviewed an email sent to the Administrator on 8/8/2022 which stated that R2 told a visitor that a staff member threw a roll of toilet paper at them. There were no other witnesses to the event. LPA was unable to interview R2 as passed away prior to the complaint being filed.
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: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20230602092816
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KING ROAD CARE HOME
FACILITY NUMBER: 315001747
VISIT DATE: 11/27/2023
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 allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Exit interview. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20230602092816
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KING ROAD CARE HOME
FACILITY NUMBER: 315001747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2023
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place . . . This requirement was not met as evidenced by observation and document review. This poses a direct
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Administrator to email LPA planned training for all staff regarding medication administration and centrally stored regulations.
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threat to the health and safety of residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5