342700321-1-4-2021-27-AS-KLEL-BWXVBF-20210104151728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700321
Report Date: 01/04/2021
Date Signed: 01/04/2021 03:18:20 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:	A LOVING AND DIVINE HOME CARE		FACILITY NUMBER:	342700321
ADMINISTRATOR:	IVANCICH, LARRY		FACILITY TYPE:	740
ADDRESS:	304 OAK CANYON WAY		TELEPHONE:	(916) 945-0259
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Larry Ivancich (Administrator)		TIME COMPLETED:	02:00 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	An office meeting was held on January 4, 2021 to follow up on a substantiated allegation of neglect/lack of supervision. Present at the conference were Laura Munoz, Acting Regional Manager; Troy Ordonez, Licensing Program Manager; Rayna Bryson Licensing Program Manager; Konnor Leitzell, Licensing Program Analyst; and the licensee A Loving and Divine Home Care, A Loving and Divine Home Care (Larry Ivancich, Tyler Ivancich, and Lisa Ivancich) On November 7, 2019, the Department concluded a complaint investigation which alleged the facility failed to seek medical attention in a timely manner. Resident 1 (R1) had an unwitnessed fall which resulted in (R1) sustaining a fractured hip. R1 was not taken to the emergency room until the day after the fall. The Department substantiated the allegation and the licensee was cited for violating California Code of Regulations (CCR) Tile 22, § 87705(j) Care of Persons with Dementia-(j) which states “The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident”, California Health and Safety Code (H&S) 1569.312(e) which states “Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.” The licensees failure to seek timely medical attention resulted in the delay of the resident being assessed by medical professionals for injuries sustained. The licensee was also cited for CCR Title 22, § 87546 Observation of the Resident which states “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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any”. The licensees failure to observe the resident’s change in condition after sustaining a fall resulted in the resident’s delay in medical attention. Cont. on LIC809C

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

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: A LOVING AND DIVINE HOME CARE	FACILITY NUMBER: 342700321
	VISIT DATE: 01/04/2021

NARRATIVE

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The investigation revealed that on September 15, 2019, R1 had an unwitnessed fall between 3:30 p.m. and 4:00 p.m. R1’s unwitnessed fall resulted in R1 sustaining a fractured hip. According to the Mayo Clinic, “the signs and symptoms of a fractured hip to include the inability to get up from a fall or to walk, severe pain in your hip or groin, inability to put weight on your leg on the side of your injured hip, bruising and swelling in and around your hip area, shorter leg on the side of your injured hip and outward turning of your leg on the side of your injured hip.”

Interviews revealed Staff 2 (S2) was taking a nap on the couch as S2 was working a double shift on September 15, 2019. Staff 1 (S1) stated S1 saw R1 in bed and assumed R1 would be in bed for a while. S1 stated S1 was cooking dinner in the kitchen. Interviews indicate there was a gap in supervision with S2 sleeping and S1 preparing dinner, which resulted in a lack of supervision to residents in care. Information provided indicate R1 walked down the hallway, opened the door leading to the garage and fell down the steps of the garage. This fall resulted in R1 sustaining a fractured hip. The door leading to the garage did not have an alarm system or signal system. There were no alerting systems put in place in R1’s room to alert staff that R1 was moving throughout the facility.

According to R1’s Physician Report dated May 12, 2019, R1 has a diagnosis of Dementia, and noted R1 has sundowning behavior, is confused/disoriented, has aggressive behaviors, and is unable to leave the facility unassisted. Physician’s report also indicated R1 was non-ambulatory. Facility case notes indicated R1 was a wanderer and had been exit seeking on the previous dates of September 2, 2019, September 7, 2019, and September 14, 2019.

According to an incident report submitted to the Department from the facility dated September 19, 2019, R1 fell at 4:00 p.m. on September 15, 2019. R1 was picked up and was able to stand though with some pain. The incident report states R1’s legs were moved around by staff without pain. R1 had minimal pain in the buttocks. According to an interview with staff, staff did not call 9-1-1 due to R1 not appear to be exhibiting pain.
Per incident report, by the next day, September 16, 2019, R1 was unable to stand. The incident report stated that S1 and S2 were busy, so it was difficult for staff to monitor R1’s wandering. Incident report also stated, "R1 was lying down in bed asleep and staff assumed R1 would be there awhile, about one hour." R1 was taken to the Emergency Room at a general acute care hospital on September 16, 2019 and was diagnosed with a hip fracture.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

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: A LOVING AND DIVINE HOME CARE	FACILITY NUMBER: 342700321
	VISIT DATE: 01/04/2021

NARRATIVE

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Based on medical records, interviews, and facility record reviews, the licensee failed provide adequate care and supervision to R1 on September 15, 2019. This led to R1 sustaining a hip fracture as a result of an unwitnessed fall approximately at 4 p.m. on September 15, 2019. The facility failed to seek timely medical care for R1. Medical care for R1 was not sought until 8 a.m. on September 16, 2019, which is the day after R1 sustained the fall.

At the time the complaint visit November 7, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an 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 or protracted loss or impairment of 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, January 4, 2021, 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. However, since an immediate civil penalty of $500 was issued on November 7, 2019 the amount of the civil penalty today will be $9,500. A copy of the LIC 421D was given to (facility representative) and originals were signed.

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

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

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: A LOVING AND DIVINE HOME CARE	FACILITY NUMBER: 342700321
	VISIT DATE: 01/04/2021

NARRATIVE

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Based on medical records, interviews, and facility record reviews, the licensee failed provide adequate care and supervision to R1 on September 15, 2019. This led to R1 sustaining a hip fracture as a result of an unwitnessed fall approximately at 4 p.m. on September 15, 2019. The facility failed to seek timely medical care for R1. Medical care for R1 was not sought until 8 a.m. on September 16, 2019, which is the day after R1 sustained the fall.

At the time the complaint visit November 7, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an 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 or protracted loss or impairment of 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, January 4, 2021, 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. However, since an immediate civil penalty of $500 was issued on November 7, 2019 the amount of the civil penalty today will be $9,500. A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. LPA provided facility with a copy of the report via email with read receipt to acknowledges facility receiving the documents. LPA requested administrator to review, print and sign one copy of the report and return it by COB 1/5/2020. LPA requested administrator to keep one copy of report for facility file. Appeal Rights provided, which are found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

LIC809 (FAS) - (06/04)

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