340313383-4-16-2024-59-AS-MSEY-D4KLLS-20240422085136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340313383
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:51:52 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
02/15/2024 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20240215152024

FACILITY NAME:	ESKATON VILLAGE		FACILITY NUMBER:	340313383
ADMINISTRATOR:	KLICK, GREG		FACILITY TYPE:	741
ADDRESS:	3939 WALNUT AVE		TELEPHONE:	(916) 974-2000
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	500	CENSUS:	DATE:	04/16/2024
		UNANNOUNCED	TIME BEGAN:	02:16 PM
MET WITH:	Chantel Krahn		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not providing resident with incontinence care.
Staff did not respond to resident’s call button.

INVESTIGATION FINDINGS:

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On 4/16/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Chantel Krahn, Resident Care Coordinator, to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

LPA Mknelly reviewed the Observation Detail List (ODL) assessment of needed services for residents who reside in Hall 1 of assisted living (rooms 16-40), as well as the call system Device Activity Report (DAR) for assisted living for the dates of 2/11/24- 2/18/24.

For the ODL’s provided for review on 2/29/24, 3 residents are identified as needing Level 4 assistance, 8 residents require Level 3 assistance, 3 require Level 2 assistance and 2 residents do not require more than basic services.
Report continued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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-20240215152024

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: ESKATON VILLAGE	FACILITY NUMBER: 340313383
	VISIT DATE: 04/16/2024

NARRATIVE

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The facility’s Admission Agreement template from 2010 in the facility file in the Sacramento CCLD office, identifies: Level Four- Extensive Assistance. Resident requires extensive assistance for personal care, bowel and bladder management, and health care monitoring. Behavior may be unpredictable and continual orientation and cueing may be needed for all basic functioning. Housekeeping and laundry needs may be more than daily. All services in Levels One, Two and Three would be required;
Level Three- Moderate assistance. Resident's needs are more intense and include moderate assistance in activities of daily living as well as constant supervision and moderate assistance for dressing and bathing. Medication administration assistance may be more complex, and health monitoring may be as often as daily (e.g., blood pressure checks). Physical assistance in preparation for and during transports outside the
facility may be necessary. Physical assistance and escort to the dining room and constant cueing and assistance during mealtimes would most likely be needed. Tray services may be used frequently. Laundry and housekeeping services may be required daily. Resident may require regular assistance in bowel and bladder
management. All services included in Levels One and Two would be required; and
Level Two- Minimal Assistance.

The DAR provided to the investigating LPA contained approximately 835 pendant calls for the week or 2/11/24-2/18/24 in Assisted Living. Of the 835 calls, LPA found that approximately 177 responses exceeded 20 minutes. Given the content of the complaint allegation, LPA then reviewed information for 2/15/24, Hall 1, and found that there were 16 call responses exceeding 19 minutes and 50 seconds. 10 of the incidents, in Hall 1 on 2/15/24, occurred on the AM shift and 6 on the PM shift. Of the residents impacted by call response delays, 4 were designated as Level Three and 1 was Level Four.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240215152024

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: ESKATON VILLAGE	FACILITY NUMBER: 340313383
	VISIT DATE: 04/16/2024

NARRATIVE

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Resident records indicate that the longest recorded response times, in Hall 1, on 2/15/24 were experienced by R1, who is Level 4, who had a wait time of 63:05 (min:sec) and R5, who is Level 3, had a wait time of 67:42 (min:sec). R1’s delay occurred at 10:48 AM and interviews conducted found that the delay resulted in a delay in incontinence care for R1. When interviewed by LPA, R5 was unable to recall the reason for their call on 2/15/24. However, R5’s ODL identifies R5 as using a catheter, needing stand-by assist for toileting, is a fall risk and requires frequent check.

CCR 87411 Personnel Requirements – General states, in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.”

LPA interviewed seven (7) residents who had recorded incidents of long (greater that 19 min 50 sec) response times. Seven of seven residents interviewed stated that while many response times are less than 15 minutes, they all have experienced response times more than 20 minutes. All seven have had staff explain delays to them as staff were providing service to another resident as the reason for the delay. All residents interviewed stated they experience routinely longer wait times around meals and bedtimes, where more residents need assistance at the same time.

LPA interviewed seven (7) caregivers. All seven stated that they have been working when call times have exceeded what they all have understood as company direction to not exceed 15 minutes. On 2/15/24, when R1 was incontinent and waiting for assistance, interviews and records found that S1 was assigned to hall one. When R1 called for assist at 10:48, S1 was assisting another resident, R2, with bathing. Staff interviews did not

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240215152024

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: ESKATON VILLAGE	FACILITY NUMBER: 340313383
	VISIT DATE: 04/16/2024

NARRATIVE

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provide specific reason why the 2 medication technicians (MT) or the other caregiver working (S2) in hall 2 did not respond timely on 2/15/24. All staff interviewed stated that reasons for delays in response times include but are not limited to insufficient staff (staff call offs), staff engaged with other residents/ duties and pager or pendant malfunctions.

As a result of this investigation, LPA 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with . Copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 59-AS-20240215152024

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: ESKATON VILLAGE	FACILITY NUMBER: 340313383
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	Managed Incontinence- (b)… the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on	1 2 3 4 5 6 7	Licensee will submit a detailed plan of care for R1 that meets the requirements of this regulation, by the POC date of 5/15/24. This plan of correction is to be applied to all residents with incontinence. Plans to be maintained on file.
	8 9 10 11 12 13 14	records and statements that on 2/15/24, R1 was not assisted with incontinence for an extended period. This posed a potential risk to the resident.	8 9 10 11 12 13 14
Type B 05/15/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) 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 based on documents and statements that showed	1 2 3 4 5 6 7	Licensee for resident call response times. The plan will address the following factors: pendants and Pagers are well maintained; a system of Communication between facility staff when unable to respond; ID of residents known to have potential urgent needs (incont., heart issues, impulsive if delayed
	8 9 10 11 12 13 14	at times there are insufficient staff to meet the needs of residents. This poses a potential risk to residents in care.	8 9 10 11 12 13 14	response , etc); A minimum general response time; Auditing of long call times; Notes for call time length errors; a system for determining staffing, in real time, based on identified needs; and whether non-care duties such as laundry require additional staff for that task.

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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