315001984-2-14-2024-59-AS-TORZ-D2WVY7-20240229155040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315001984
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:33:48 AM

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
09/11/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230911115419

FACILITY NAME:	BRIGHT HORIZONS CARE HOME		FACILITY NUMBER:	315001984
ADMINISTRATOR:	BUCOVATI, SHEILA		FACILITY TYPE:	740
ADDRESS:	232 NERISSA COURT		TELEPHONE:	(916) 746-0144
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 5	DATE:	02/14/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator: Florin Bucovati		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff did not prevent a resident from eloping from the facility.

INVESTIGATION FINDINGS:

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LPA Keosavang, conducted this visit to change the findings from unfounded to substantiated. This reports supercedes the report done on 2/09/2024.

On 02/14/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 09/11/2023. LPA met with administrator, Florin Bucovati, and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews with facility staff and obtained pertinent documents relevant to the complaint investigation such as residents’ (R1 and R2) physician’s report, incident reports, confidential facsimile transmittal, medication administration records, and medication list.

Continue on page LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 59-AS-20230911115419

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: BRIGHT HORIZONS CARE HOME	FACILITY NUMBER: 315001984
	VISIT DATE: 02/14/2024

NARRATIVE

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The Department conducted interviews and reviewed records regarding the allegation that staff did not prevent a resident from eloping for the facility.

On 08/07/2023, the Department received a telephone call from administrator, Sheila Bucovati, to report an incident that occurred at the facility. The administrator submitted an unusual incident report for review. According to the incident report, on 08/07/2023 at approximately 6 AM, R2 managed to walk out of the facility front door. The staff were assisting other residents in their care with their showers at the time and heard the front door alarm sound. The staff immediately went to conduct rounds to check on residents in care. The staff noticed R2 was missing and walked outside to locate R2. R2 was located a few houses from the facility. The staff were able to redirect R2 back to the facility. Based on interviews conducted, it took staff approximately 5 minutes to locate R2. At the time of the incident, R2’s power of attorney (POA) was notified. The facility put a plan in place for R2 which included engaging R2 with more one on one observation to keep R2 from distraction and wandering away from the facility. R2 did not sustain any bodily injury as a result of R2’s elopement from the facility.

The Department reviewed R2’s physician’s report. According to physician’s report, R2 can be confused/disoriented, has wandering behavior, and is unable to leave the facility unassisted.

Although the facility did their due diligence by reporting the incident to the licensing agency and R2’s POA via telephone no later than the next working day and in writing within 7 calendar days, staff did not provide R2 with proper supervision resulting in R2 eloping from the facility.

As a result of this investigation, the Department finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are being cited for today's visit.

Exit interview conducted and report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230911115419

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: BRIGHT HORIZONS CARE HOME	FACILITY NUMBER: 315001984
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/23/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and records review, R2 eloped from the	1 2 3 4 5 6 7	Licensee agrees to submit an elopment plan to ensure residents in care do not elope from the facility. Licensee agrees to submit POC by due date, 2/23/2024.
	8 9 10 11 12 13 14	facility which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC9099 (FAS) - (06/04)

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