342700201-12-28-2020-27-AS-ATUK-BWQUHZ-20201228143645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 12/28/2020
Date Signed: 12/28/2020 02:39:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	LOVE AND SERENITY OF ELK GROVE II		FACILITY NUMBER:	342700201
ADMINISTRATOR:	BIANCA CASTRO		FACILITY TYPE:	740
ADDRESS:	9279 ORANGE CREST COURT		TELEPHONE:	(916) 897-9287
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	12/28/2020
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Binca Castro		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A case management visit was conducted on 12/28/2020 via video call due to COVID to follow up on a substantiated allegation of neglect/lack of supervision. Present during the call was Stephenie Doub, Licensing Program Manager; Licensing Program Analyst Anthony Tuck Administrator Bianca Castro, Love and Serenity of Elk Grove LLC. On August 22, 2019, the Department conducted a complaint investigation which alleged the following: Lack of supervision resulted in a resident sustaining multiple serious injuries. The allegations were substantiated, and the licensee was cited for violating California Code of Regulation (CCR) Title 22, § 87411 (a) Personnel Requirements: Facility shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. On April 6, 2019, there was only one staff present at the facility when Resident 1 (R1) went AWOL from the facility. When R1 went AWOL, R1 fell sustaining injuries which included head trauma, a broken nose and a broken jaw. The investigation revealed that R1 moved into Love and Serenity of Elk Grove II on March 25, 2019 R1’s medical evaluation report (LIC 602) diagnosed (R1) with dementia and documented that R1 was unable to leave the facility unassisted. On April 06, 2019, R1 wandered from the facility alone and was found by bystanders on the ground approximately 0.4 miles from the facility. Bystanders reported that R1 was alone when R1 fell and that the bystanders called 9-1-1. The treating paramedics and bystanders stated that the facility staff arrived on the scene after first responders arrived, and that the staff had informed them that they had been looking for R1 all morning. The treating paramedics subsequently transported R1 to the emergency room. Continued on 809C...

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II	FACILITY NUMBER: 342700201
	VISIT DATE: 12/28/2020

NARRATIVE

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Based on a review of the medical report, on April 6, 2019, R1 was found AWOL from the board and care, in the prone position and brought in by ambulance (BIBA) (R1 was located in a prone position at an intersection with head trauma). Resident 1 (R1) was admitted to a general acute care hospital on April 6, 2019. The medical report stated that R1 had sustained a broken nose, and a fracture of the jaw (right side). Based on staff interviews, it was determined that staff (S1) was assisting another resident when R1 wandered off the property. It was also reported that (S1) was the only staff on duty at the time of R1's AWOL. Staff interviews further revealed that R1 had AWOL from the facility at least twice prior to the April 06, 2019 AWOL. Interviews conducted with R1's responsible party revealed that R1’s responsible party and spouse of R1’s responsible party witnessed two prior instances where R1 attempted to leave the facility. The R1’s responsible party also stated during an interview that the responsible party only witnessed one care provider at the facility when the responsible party visited, and the concern about staffing was previously discussed with the facility; suggesting that facility install a keypad entry system for the door of the facility. Further, staff interviews revealed that R1's responsible party told staff that R1 had a history of wandering and that R1’s responsible party was concerned about R1 eloping.

Based on interviews and records reviewed, the licensee failed to have adequate staffing. There is sufficient evidence that facility caregivers were aware of R1's propensity to elope from the facility, especially during daytime hours. Evidence showed only one caregiver on duty at the time R1 eloped. Due to R1's propensity to elope, the licensee failed to provide at least one other caregiver on duty at the time of R1's elopement. As a result of the AWOL, R1 fell and sustained a broken nose and a broken maxillary (jaw) bone, which is a serious bodily injury.
Approved for Issuance – Love and Serenity of Elk Grove II - #342700201
On November 6, 2020 during a Case Management visit, the licensee was notified that the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

Continued on 809C...

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II	FACILITY NUMBER: 342700201
	VISIT DATE: 12/28/2020

NARRATIVE

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The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, _12/28/2020_ the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. A copy of the LIC 421D was given to (facility representative) and originals were signed.

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

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020

LIC809 (FAS) - (06/04)

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