342700005-10-27-2021-27-AS-KHOS-C89L6Q-20211029082908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700005
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:24:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210712163451

FACILITY NAME:	REVERE COURT		FACILITY NUMBER:	342700005
ADMINISTRATOR:	CHAPPELL, BRENDA		FACILITY TYPE:	740
ADDRESS:	7707 RUSH RIVER DRIVE		TELEPHONE:	(916) 392-3510
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	72	CENSUS: 71	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	11:47 AM
MET WITH:	Brenda Chappell		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained major injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/27/21 at 11:47am to conclude the investigation regarding the above-mentioned allegation. LPA met with Brenda Chappell and discussed the purpose of the visit.

LPA requested a copy of the Admission agreement including the Respite agreement for resident #1 (R1), contact phone numbers of staff, and Admission Record (Face Sheet).

Regarding allegation, “Resident sustained major injury while in care”, LPA reviewed facility documents and medical records and conducted interviews.

LPA observed a Special Incident Report (LIC624(SIR)) dated 7/9/21 that indicates resident #1 (R1) fell and was sent to the emergency room for a cheek laceration.

Unsubstantiated

Estimated Days of Completion: 120

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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 27-AS-20210712163451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REVERE COURT	FACILITY NUMBER: 342700005
	VISIT DATE: 10/27/2021

NARRATIVE

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A review of the first Physician Communication Fax (PCF) dated 7/9/21 revealed that R1 was found on the floor with cut to right cheek and was sent to the hospital, the 2nd (PCF) dated 7/10/21, revealed that R1 was sent to the hospital for a swollen left knee and notified there was a fracture to the Patella. LPA observed the Physician report(s) dated 2/2/20 and 2/21/21 which indicates that R1 walks/wanders and able to independently transfer to and from bed. A review of the Transfer of Care Summary dated 7/9/21, revealed that R1 was diagnosed with Closed fracture of fourth cervical vertebra; Face laceration. The Transfer of Care Summary dated 7/10/21, revealed R1 was diagnosed with Displaced comminuted fracture of right patella, initial encounter for closed fracture.

LPA observed that during interviews of Staff #1 (S1-S6) and physician report all corroborate that R1 was able to ambulate (walk/wander) without the use of any devices. The investigation revealed that S1 was finishing laundry duties when R1 arrived at the dining area. S1 began walking with R1 to the chair that was familiar to R1. S1 turned to relocate a hamper to ensure it would not become a hazard when S1 heard the chair R1 had was sliding away from the resident. By the time S1 tried to grab the chair, R1 had already fallen to the floor. S1 called for help when S2 arrived who called 911 and S3.

Based on interviews, documentation, and medical records, there appears to be no negligence on behalf of the staff. The facility reported the incident timely seeking immediate medical attention, to Responsible party (RP), Primary Care Physician (PCP), and Community Care Licensing (CCL) for R1. LPA observed that the requirement of ensuring that dementia care residents have an annual assessment was completed. LPA did not observe documentation on the 2020 physician report or the 2021 physician report that indicated R1 needed 1:1 care nor did R1 have any motor impairment/paralysis.

The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC9099 (FAS) - (06/04)

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