317005513-9-29-2021-25-AS-SKEG-C7BPLG-20210929112444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 09/29/2021
Date Signed: 09/29/2021 11:24:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	STERLING COURT AT ROSEVILLE		FACILITY NUMBER:	317005513
ADMINISTRATOR:	DOWELL, CAROL		FACILITY TYPE:	740
ADDRESS:	100 STERLING CT		TELEPHONE:	(916) 786-7200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	128	CENSUS: 68	DATE:	09/29/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marianne Richardson- Executive Director		TIME COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Sarena Keosavang and Pheej Cheng arrived at the facility unannounced on 09/29/2021 to conduct a Case Management visit as directed by the Department. LPAs met with Executive Director, Marianne Richardson, and explained the purpose of the visit. Prior to initiating the Case Management visit, LPAs 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 and contacted licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPAs were screened by facility staff upon entering the facility.

An office meeting was held on January 7, 2021, to follow up on substantiated allegations. Present in the meeting is Licensing Program Manager (LPM), Anthony Perez; LPM Laura Munoz; Licensing Program Analyst (LPA), Sarena Keosavang; Brookdale Sterling Court District Director of Operations, Sharon Monck; Interim Executive Director, Ed Silva; Clinical Service Registered Nurse, Alicia Scott; Vice President of Operations, Deirdre Brown; Counsel, Joel Goldman; and Nurse, Jina Amstutz.

On December 1, 2020, the Department concluded a complaint investigation and substantiated an allegation that staff failed to seek timely medical attention for resident (R1) while in care, questionable death, and facility failed to meet R1’s needs.

The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(g) Incidental Medical and Dental Care- (g) which states, “ 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).

************************************** Continue on LIC 809-C **************************************

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: STERLING COURT AT ROSEVILLE	FACILITY NUMBER: 317005513
	VISIT DATE: 09/29/2021

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California Health and Safety Code (H&S) § 1569.312(e) Basic Services Requirements which states, “Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. California Health and Safety Code (H&S) § 1569.269(a)(6) Enumerated Right- (a) which states, “Residents of residential care facilities for the elderly shall have all of the follow rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

The investigation revealed that on January 4, 2020, at approximately 6 a.m. R1 had an unwitnessed fall prior to be checked on; however, R1 showed no signs of pain and only had visible injury of a skin tear which staff (S1) bandaged. Per facility fall policy, when a resident sustains an unwitnessed fall 9-1-1 is to be called and the resident is to be evaluated and sent to the hospital if needed. S1 claimed they were not informed of R1’s incident and that at approximately 7 a.m. a Staff (S4) requested S2’s to help assist R1 out of bed. R1 was showing signs of pain and was observed to be unsteady. S2 and S4 transferred R1 into a wheelchair. S2 told the Department that a nurse (S5) and the Interim Executive Director (ED) did evaluate R1 that morning. Interviews with facility nurses revealed that R1 was not assessed the day of the fall by a nurse at the facility, furthermore Interim ED was not present in the facility that day.

Documents revealed R1 was ambulatory and was able to transfer on their own, S2 stated that a wheelchair was used for R1 that day because they observed R1 to be wobbly when transferred. S2 also indicated R1 was placed in wheelchair to prevent R1 from falling. The Department was told in interviews with facility staff that R1 did not normally use a wheelchair. Use of wheelchair indicated R1 was not at their baseline and a change of condition had occurred.

Documents reviewed and interviews conducted revealed that at approximately 9 a.m. R1 was displaying signs of pain and trying to stand up. S2 told the Department during interviews that R1 stated R1 was in pain but did not say where, S2 was unable to determine where the pain was coming from when evaluating R1. S2 attempted to contact R1’s responsible party (RP) at approximately 9 a.m. and was unable to make contact. At approximately 11 a.m. the RP was reached and R1 had still not been sent out or evaluated by 9-1-1. RP arrived at the facility at approximately 11:40 a.m., 9-1-1 was called for R1 at approximately 1 p.m., and R1 was transferred to the hospital where an X-Ray of R1’s pelvis revealed a left femoral (Femur- the long bone that extends from the pelvis to the knee- mayoclinic.org) neck fracture.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: STERLING COURT AT ROSEVILLE	FACILITY NUMBER: 317005513
	VISIT DATE: 09/29/2021

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The Department was told in interviews with facility staff that the facility policy following an unwitnessed fall is to have a nurse evaluate the resident and to contact 9-1-1 for the resident to be sent to the hospital for further evaluation. The facility did not contact 9-1-1 for R1 on January 4, 2020 after a suspected unwitnessed fall with visible injury despite that being their policy, additionally, R1 was never evaluated by a facility nurse for the fall. R1 was discharged to a different facility from the hospital on January 8, 2020 on hospice and passed away on January 27, 2020. Per Death Certificate, cause of death was Cardiopulmonary Arrest with secondary causes -left femoral neck fracture, accidental fall and dementia-etiology unknown. The Department reviewed documentation that showed R1 had history of falls on the dates: March 14, 2016, March 15, 2016, November 24, 2017, December 1, 2017, December 21, 2017, December 25, 2017 and ultimately January 4, 2020. On November 24, 2017, R1 was sent to the Emergency Room and December 1, 2017, R1 was evaluated by 9-1-1 for complaints of shoulder pain. R1 had two incidents within a week. On December 21, 2019, and December 25, 2019, and January 4, 2020, facility documents show R1 suffered from three unwitnessed falls within eight days. Staff interviews revealed R1 had history of falls, was a fall risk. R1 was placed on Temporary Service Plans (TSP) following the December 21, 2019 and December 25, 2019 falls. TSP indicated that R1 was to be monitored more frequently, every 30 minutes to an hour and to be taken to and from activities in the community. R1’s personal care plan, TSP’s and other documents reviewed all indicated R1 suffered multiple unwitnessed falls with no intervention other than frequent checks of R1 and to assist R1 to activities. Based on this information the facility did not meet the needs of R1 as indicated on R1’s Personal Care Plan and TSP.

Based on interviews, record review, and medical records, the licensee did not meet R1’s needs and did not seek timely medical care for R1 on January 4, 2020 when R1 had an unwitnessed fall which resulted in R1 sustaining a left femoral neck fracture. The licensee’s failure to seek timely care caused R1 to suffer serious bodily injury, which required hospitalization. Medical care for R1 was not sought out until 1 p.m. on January 4, 2020, which is approximately seven (7) hours after a caregiver observed visible injuries on R1. On January 27, 2020 R1 passed away. Per Death Certificate, cause of death was Cardiopulmonary Arrest with secondary causes -left femoral neck fracture, accidental fall and dementia-etiology unknown.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: STERLING COURT AT ROSEVILLE	FACILITY NUMBER: 317005513
	VISIT DATE: 09/29/2021

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At the time the complaint visit December 1, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for R1’s death. Today, (DATE to be Determined), the Department will be issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $15,000 for the death of R1. However, since an immediate civil penalty of $500 was issued on December 1, 2020, the amount of the civil penalty today will be $14,500.

A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. (facility representative) signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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