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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700240
Report Date: 04/04/2024
Date Signed: 04/04/2024 01:15:29 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
09/05/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230905121646
FACILITY NAME:ROYAL PALMS CARE HOMEFACILITY NUMBER:
342700240
ADMINISTRATOR:DANIELA PODARFACILITY TYPE:
740
ADDRESS:8675 PHOENIX AVETELEPHONE:
(916) 477-1554
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Daniela Podar, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident was hospitalized due to staff neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Daniela Podar, to deliver findings into the complaint allegation listed above.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
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 7
Control Number 59-AS-20230905121646
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: ROYAL PALMS CARE HOME
FACILITY NUMBER: 342700240
VISIT DATE: 04/04/2024
NARRATIVE
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Per R1's records, R1 was admitted to the hospital on 8/28/2023 with a chief complaint of generalized weakness and Urinary Tract Infection (UTI). Records state that R1 reported to have abdominal pain and poor oral intake for the past three days prior to admission. On 9/3/2023, R1 was discharged from the hospital with a UTI and generalized weakness. Interview with R1's responsible party (RP) indicated that R1 moved to the facility on 7/8/2023 and was able to use their walker, go to the bathroom, and communicate with others in the home. RP stated that they noticed R1 getting weaker and having a harder time communicating. Interview with staff (S1) indicated that they noticed R1 getting weaker while working with R1. S1 stated that they did not notice any signs of a UTI regarding R1, but stated that they were not educated on the signs to look for related to a UTI. Administrator stated that R1 was showing signs of a UTI five days prior to being sent to the hospital on 8/28/2023. Follow-up interview with Administrator indicated that they noticed a change in condition with R1 five days prior to them being sent to the hospital on 8/28/2023, but did not suspect R1 having a UTI until three days prior to R1 being sent to the hospital on 8/28/2023. Administrator stated that the signs were not severe or urgent.

RP and Administrator attempted to get a hold of R1's doctor to obtain an order for a urine sample. Administrator stated that R1 was showing signs of weakness and confusion, and R1's urine had an odor. It was not until 8/28/2023 that R1 was declining to eat meals. Administrator stated that once R1 stopped eating and missed two meals, Administrator called 911 and sent R1 to the hospital. Administrator indicated that R1 had prostate cancer and, therefore, had frequent UTIs. Administrator stated that R1 did not sustain a UTI due to anything done by the facility.

Per R1’s Physician’s Report dated 7/6/2023, R1 was diagnosed with Dementia. R1’s records also indicated that R1 had prostate cancer and bowel and bladder impairment, requiring assistance with toileting. R1's records indicated that they were able to communicate their needs and ambulate with their walker.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20230905121646
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: ROYAL PALMS CARE HOME
FACILITY NUMBER: 342700240
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87466
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87466 Observation of Resident - The licensee shall ensure that residents are regularly observed for changes in physical (...) functioning and that appropriate assistance is provided when such observation reveals unmet needs. (...) This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87466. Facility will submit statement to LPA by POC due date of 4/5/24.
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Based on interviews conducted and records reviewed, the facility did not ensure resident R1 received timely medical attention after observation of unmet needs, which poses an immediate health, safety, and personal rights risk to the residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/05/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230905121646

FACILITY NAME:ROYAL PALMS CARE HOMEFACILITY NUMBER:
342700240
ADMINISTRATOR:DANIELA PODARFACILITY TYPE:
740
ADDRESS:8675 PHOENIX AVETELEPHONE:
(916) 477-1554
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Daniela Podar, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide activities for the residents in care

Licensee did not provide a copy of the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Daniela Podar, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20230905121646
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: ROYAL PALMS CARE HOME
FACILITY NUMBER: 342700240
VISIT DATE: 04/04/2024
NARRATIVE
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A review of resident (R1's) Admission Agreement indicates the following regarding activities: "We shall offer an individualized program of recreational activities based on cooperative planning by the facility, family, caregivers, physician, and rapport and communication with the resident, and responsive, creative, and fluid planning of recreational activities. Residents and families are interviewed to gather information on their personal beliefs, culture, values, attention span and life experiences to determine activities that residents will enjoy and benefit from. The Administrator shall arrange for utilization of community recourses and promote resident participation in community-centered activities."

During multiple visits conducted by LPA, LPA observed a sufficient amount of resources for activities for the residents and observed residents participating in activities at the facility. Interviews conducted with residents R2, R3, R4, and R5 indicated that the residents have plenty of activities to participate in at the facility and they have no concerns regarding activities at the facility.

Interview with Administrator indicated that they gave a copy of R1's Admission Agreement to R1's responsible party (RP) a few days after the agreement was signed. Administrator stated that they gave R1's RP another copy of the agreement when R1 moved out of the facility. Administrator stated that R1's RP never requested another copy of R1's Admission Agreement during the time that R1 resided at the facility. LPA observed R1's Admission Agreement signed by R1's RP and dated for 7/8/2023.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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.

Licensee gave permission to have Acting Administrator, Denisa Crisan, sign report.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/05/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230905121646

FACILITY NAME:ROYAL PALMS CARE HOMEFACILITY NUMBER:
342700240
ADMINISTRATOR:DANIELA PODARFACILITY TYPE:
740
ADDRESS:8675 PHOENIX AVETELEPHONE:
(916) 477-1554
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Daniela Podar, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not issue refund to resident's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Daniela Podar, to deliver findings into the complaint allegation listed above.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20230905121646
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: ROYAL PALMS CARE HOME
FACILITY NUMBER: 342700240
VISIT DATE: 04/04/2024
NARRATIVE
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On 9/1/2023, the Department received a phone call from R1's responsible party (RP) indicating that R1's personal property had yet to be removed from the facility as of 9/1/2023.

During visit conducted on 3/13/2024, LPA obtained documentation from Administrator showing proof of refund to R1's RP in relation to the date in which R1's personal property was removed from the facility.

Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7