342700202-11-14-2022-25-AS-DAWL-CL6SYA-20221114131714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700202
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:32:08 PM

Document Has Been Signed on 11/14/2022 01:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	VILLAGE AT HERITAGE PARK, THE		FACILITY NUMBER:	342700202
ADMINISTRATOR:	KAYLA DAVIS		FACILITY TYPE:	740
ADDRESS:	2001 ROSE ARBOR DRIVE		TELEPHONE:	(916) 216-8958
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	108	CENSUS: 105	DATE:	11/14/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Malissa Acuna, Executive Directorr		TIME COMPLETED:	01:45 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	On November 14, 2022, Licensing Program Analysts (LPA) De Anna Williams-Lyons conducted a case management inspection to follow up on a substantiated complaint allegation of staff who were unaware of resident’s whereabouts, the resident’s care needs were not met after a fall that led to serious bodily injury, and the resident was in extreme pain for more than 24 hours. LPA De Anna Williams-Lyons met with Executive Director Malissa Acuna and explained the purpose of the visit. On September 27, 2022, the Department concluded a complaint investigation and substantiated allegations of questionable death; staff being unaware of resident's whereabouts; and resident's care needs not being met. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation, including medical records. On May 17, 2022, the department received a complaint regarding the death of a resident (R1). On May 24, 2021, R1 signed an admission agreement with the facility and moved into the facility on May 26, 2021. Interviews with the Administrator indicated that they were aware that R1 was moving into the facility, however, they acknowledged that care staff were not aware of R1's move in. A review of R1's needs and service plan indicated that R1 was at risk for falls and staff would monitor. To continue see 809-C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 11/14/2022

NARRATIVE

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809-C2

A review of R1's LIC602, Physician Report, dated May 19, 2021, documented R1's medical diagnoses history of prostate cancer, Hypertension (HTN), Hypothyroidism, and Mild Cognitive Impairment. R1 was documented as ambulatory, however, used a cane for mobility assistance.

On May 28, 2021 at 10:05 a.m., R1's responsible party (RP) visited the facility to see R1. RP went to R1's apartment and upon entering R1's room, RP observed R1's front door was unlocked. When RP entered the apartment, RP found blood on the floor and the bedroom door was closed. RP entered the bedroom and found R1 laying on the floor between the bedroom and bathroom. There was blood on R1's bed. R1 was only wearing a blood soaked undershirt and underwear and had defecated on themselves. RP asked R1 what happened, and R1 stated that they had fallen sometime on Thursday, May 27, 2021.
Interviews with staff indicated that vacant rooms of the facility are not checked, and that because staff were not aware that R1 had moved into the facility, they did not check the room R1 moved into.

On May 28, 2021, 9-1-1 was called at approximately 10 a.m. Emergency Medical Technician (EMT) records indicated that they found R1 lying on the ground. The patient seemed to be in mild distress. R1 was observed to have an inch laceration that was not bleeding on their forehead. R1 was also observed to have bruising to the right eye.

Upon admittance to the hospital on May 28, 2021 at 12:00 p.m., R1 was diagnosed with Bilateral subdural hematomas, forehead laceration, and was put on comfort care.

To continue see 809-C3...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 11/14/2022

NARRATIVE

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809-C3
Based on the investigation, the facility failed to ensure that staff were aware that R1 had moved into the facility. R1's needs and service plan indicated R1 was a fall risk which required staff to monitor. As a result of staff’ failing to meet R1's needs, R1 sustained a fall in which timely medical assistance was not sought.

The above allegations were substantiated on September 27, 2022, and deficiencies were cited for violating the following California Code of Regulations (CCR) Title 22:

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities-
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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.

87405(d) Administrator - Qualifications and Duties
The administrator shall have qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, requirements for an administrator shall apply.

87465(g) Incidental Medical and Dental Care
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).

To continue see 809-C4

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VILLAGE AT HERITAGE PARK, THE	FACILITY NUMBER: 342700202
	VISIT DATE: 11/14/2022

NARRATIVE

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809-C4
At the time of the compliant visit on September 27, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining a serious bodily injury while under the care of this facility. The 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.” This is evidenced by the licensee’s failure to ensure proper care, supervision, and failure to seek timely medical care for R1 resulting in R1 sustaining seriously bodily injury from a fall at the facility.

Today, November 14, 2022, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation the Department determines resulted in R1 sustaining serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on September 27, 2022, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to the Executive Director and originals were signed.

Exit interview conducted. A copy of the report was issued. Appeal Rights provided. Malissa's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC809 (FAS) - (06/04)

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