315002345-7-30-2021-27-AS-MSEY-C5ETHG-20210730144443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002345
Report Date: 07/30/2021
Date Signed: 07/30/2021 11:53:58 AM

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
09/16/2020 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20200916103940

FACILITY NAME:	SENIOR CARE VILLA OF LOOMIS		FACILITY NUMBER:	315002345
ADMINISTRATOR:	ROXANA BUCURENCIU		FACILITY TYPE:	740
ADDRESS:	3400 CHISOM TRAIL		TELEPHONE:	(916) 652-8000
CITY:	LOOMIS	STATE: CA	ZIP CODE:	95650
CAPACITY:	27	CENSUS: 26	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Roxana Bucurenciu, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to seek timely medical care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with Roxana Bucurenciu during today’s visit. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.
The department investigated “Facility failed to seek timely medical care”. The department conducted interviews and conducted a record review. According to interviews Administrator reported that a “boil” was observed and treated with barrier cream in the evening of 9/13/20.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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 27-AS-20200916103940

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: SENIOR CARE VILLA OF LOOMIS	FACILITY NUMBER: 315002345
	VISIT DATE: 07/30/2021

NARRATIVE

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Staff stated that R1 seemed weaker the night before 9/13/20 when walking to the bathroom when the “boil” was found. Multiple staff stated the boil was unopened that evening and administrator did not notify R1 responsible party or physician.
Multiple sources of documentary evidence were obtained and reviewed that state emergency services were called on 9/14/20 because R1 was suspected of having a stroke due to their lethargy that morning. Administrator reported that she checked R1 between 0600-0630 on 9/14/20 and found him not responding normally. Administrator later said it may have been later, between 0700-0800 hours. Staff reported that R1 was “very weak” on 9/14/20 and they had to change R1 in bed because he could not get up to go to the bathroom. Staff stated they helped changed R1 in bed and then left work at about 0800 hours. Staff reported they knew R1 was still in bed when they left for work. Administrator stated they called immediately after finding R1 that morning of 9/14/20 due to suspicions of a stroke and that the wound was not a concern. The department reviewed recorded audio call from the call to the emergency services. Administrator placed a call to ambulance services not 911 on 9/14/20 at 9:19:49 hours. Administrator told the dispatcher that R1 needed a transport for IV antibiotics only. Administrator told the dispatcher that the boil had “opened up” the previous night, and R1 has a diagnosis of dementia but is at “baseline”. The department finds administrator checked on R1 at approximately 0600-0630 and did not call emergency services until 0914 hours. Due to the information gathered LPA finds allegation to be SUBSTANTIATED.
The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached 9099-D.
Appeal rights provided. Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20200916103940

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: SENIOR CARE VILLA OF LOOMIS	FACILITY NUMBER: 315002345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/02/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (g) 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).	1 2 3 4 5 6 7	Administrator agrees to conduct a training for all staff from an outside vendor on when to call emergency services. Date of training to be sent to CCL by 8/2/21.
	8 9 10 11 12 13 14	This requirements not met as evidenced by: Based on interviews and records review the licensee did not call emergency services in a timely manner which poses an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14	Once training has been completed, administrator to send the training documents and sign in sheet.
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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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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
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
09/16/2020 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 27-AS-20200916103940

FACILITY NAME:	SENIOR CARE VILLA OF LOOMIS		FACILITY NUMBER:	315002345
ADMINISTRATOR:	ROXANA BUCURENCIU		FACILITY TYPE:	740
ADDRESS:	3400 CHISOM TRAIL		TELEPHONE:	(916) 652-8000
CITY:	LOOMIS	STATE: CA	ZIP CODE:	95650
CAPACITY:	27	CENSUS: 26	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Roxana Bucurenciu, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with Roxana Bucurenciu during today’s visit. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
The department investigated “Resident sustained a pressure injury while in care”. The department conducted interviews and reviewed resident records. R1 was admitted to the hospital on 9/14/20 with an “unspecified injury stage necrotic debitus ulcer with cellulitis and severe sepsis”.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20200916103940

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: SENIOR CARE VILLA OF LOOMIS	FACILITY NUMBER: 315002345
	VISIT DATE: 07/30/2021

NARRATIVE

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Medical records documented that “the necrotic ulcer is foul-smelling and much older than 24 hours.” R1 did not respond to treatment at the hospital. The emergency department physician was interviewed and stated, due to the necrotic nature of R1 ulcer, with skin that had died and then scabbed, the wound could not have happened in 24 hours. Physician stated, “this is not what a boil looks like that is only a day old,” and that facility staff were wither lying or had not been looking at R1’s backside. The department interview physical therapist who provided wound care for R1 on 9/15/20 and stated it was possible, based on their observations of the wound and R1’s overall health indicators, that R1 would could have developed from a boil between the evening of 9/13/20 and the morning of 9/14/20. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
Although the allegation may have happened or is valid, the Department have found the allegation to be unsubstantiated.
Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5