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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700029
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:35:06 AM

Substantiated


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
09/30/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220930164204
FACILITY NAME:CALI CARE RETIREMENT HOMEFACILITY NUMBER:
342700029
ADMINISTRATOR:MOJICA, CYNTHIAFACILITY TYPE:
740
ADDRESS:3630 WEST WAYTELEPHONE:
(916) 484-3027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Emmanuel A Mojica TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not address a resident's needs while in care.
Resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
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On 10-11-2022 at 11:20 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Emmanuel A Mojica and explained the purpose of today's visit.

Throughout the complaint investigation, LPA Martinez reviewed documents and conducted interviews. It was learned resident 1 (R1) has a history of pressure injuries. R1 developed a pressure injury on their foot last year in 2021. In addition, R1 developed a pressure injury on their buttocks 11 days ago. Moreover, During a 10/04/2022 facility visit, it was learned the facility had not conducted a reassessment due to R1's newly developed pressure injury. LPA Martinez was also informed the facility did not report the pressure injury to R1's primary care physician. Additionally, at the 10/04/2022 visit, the facility staff did not know the stage of the pressure injury, and R1 was not being provided wound care.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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 3
Control Number 27-AS-20220930164204
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: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029
VISIT DATE: 10/11/2022
NARRATIVE
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At the 10/04/2022 visit, LPA Martinez advised staff 1 (S1) to get in contact with R1's primary care physician in regards to the newly developed pressure injury. LPA Martinez also advised (S1) to obtained wound care directives from R1's primary care physician and to obtain information on the stage of the pressure injury. It was not until 10/10/2022 that R1 had a medical appointment, and at this appointment it was learned R1 has a stage 2 pressure injury and home health was ordered.

As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220930164204
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: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidence by:
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Administrator agrees to conduct Observation of the residents training for all staff by POC date 10/25/2022. Administrator will email LPA Martinez training documents by 10/25/2022.
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Based on record review and interviews, the licensee did not ensure staff provided the appropriate assistance and care and supervision to meet R1's newly developed pressure injury needs. This posed a potential health and safety risk to R1.
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Type B
10/25/2022
Section Cited
CCR
87464(f)(1)
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87464 (f) (1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by:
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Administrator agrees to conduct Basic Services training for all staff by 10/25/2022. Administrator will email LPA Martinez training documents by POC Date 10/25/2022.
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Based on record review and interviews, the licensee did not ensure that staff addressed R1's pressure injury and report pressure injury to R1's primary care physician and did not ensure R1 received proper pressure injury care. This posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3