342700326-12-31-2020-27-AS-BHUT-BWTQ7G-20201231105507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700326
Report Date: 12/31/2020
Date Signed: 12/31/2020 10:56:18 AM

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:	ROSEBERRY CARE		FACILITY NUMBER:	342700326
ADMINISTRATOR:	QUISTGUARD, JESSICA		FACILITY TYPE:	740
ADDRESS:	128 BERRY STREET		TELEPHONE:	(916) 780-3369
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	15	CENSUS: 12	DATE:	12/31/2020
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jessica QuistGard, Administrator Jimelia Sterling, Administrator		TIME COMPLETED:	11:00 AM

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 12/31/20 Licensing Program Analyst (LPA) Bethany Huusfeldt, spoke with Administrator, Jessica Quistgard & Jimelia Sterling, of Roseberry Care to follow up on a substantiated allegation of that the facility staff failed to seek medical attention in a timely manner for a resident. Due to COVID-19 precautions, LPA was unable to meet in person with administrators. On October 8, 2019, the Department concluded a complaint investigation and substantiated the allegation that the facility staff failed to seek medical attention in a timely manner for a resident. The allegation was substantiated, and the licensee was cited for violating California Code of Regulation (CCR) Title 22, section § 87465(g) Incidental Medical and Dental Care: The facility failed to seek timely medical care for resident. Resident (R1) sustained a secondary hip fracture and suffered extreme pain because staff did not seek timely medical treatment for eighteen hours following an unwitnessed fall that occurred on June 18, 2019. On June 19, 2019, medical records indicate (R1) was diagnosed with a secondary hip fracture. A review of the medical records revealed that (R1) had a diagnosis of dementia and had previously sustained a hip fracture on April 29, 2019 requiring hip replacement surgery. (R1) was later admitted to the Roseberry Care Facility on May 15, 2019. R1’s pre-placement appraisal notes the recent hip fracture requiring surgery. It was further noted on the appraisal that R1 is non-ambulatory, and requiring a two-person assist. Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

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: ROSEBERRY CARE	FACILITY NUMBER: 342700326
	VISIT DATE: 12/31/2020

NARRATIVE

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The investigation revealed that on June 18, 2019, two staff were on duty caring for residents at the facility. Interviews determined the residents were in the living room watching television; one staff (S1) was down the hallway; and the other staff (S2) was in the kitchen preparing dinner. It was reported that (S2) observed R1 attempt to get up from R1’s chair in the living room, and (S2) instructed R1 to wait for assistance, however, (S2) was unable to provide assistance in time to prevent R1 from sustaining a fall. Interviews indicated R1 fell against a chair and onto another resident’s legs, sliding to the floor. Interviews indicate R1 was observed falling on the hip that was recently fractured and surgically replaced. Interviews further revealed that staff subsequently noticed an abrasion to R1’s arm, which staff cleaned and bandaged. After attending to R1, staff reported they notified the administrator via text message. Staff also stated they recorded the incident in the logbook and observed R1 over the next few hours.

The investigation determined that although the Administrator knew of R1’s recent hip surgery, the Administrator did not immediately go to the facility to examine R1. Rather, the Administrator waited until the following morning to go to the facility to assess R1. Despite the Administrator’s and Staff knowledge of the resident’s recent hip fracture as noted in the pre-placement appraisal, and resulting hip surgery, the facility failed to call 9-1-1 or seek emergency medical attention from June 18, 2019, 4:00 p.m. (approximate time of the resident’s fall), to June 19, 2019 between 10:00 a.m. and 10:30 am, which was over eighteen hours later. Further, the 9-1-1 call was eventually made at the resident’s Occupational Therapist’s (OT) direction, not by the Administrator or staff. On June 19, 2019, medical records indicate (R1) was diagnosed with a secondary hip fracture.

At the time of the complaint visit on October 8, 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.

Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

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: ROSEBERRY CARE	FACILITY NUMBER: 342700326
	VISIT DATE: 12/31/2020

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, 12/30/20 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 previously issued on October 8, 2019, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Jessica Quistgard & Jimelia Sterling and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Jessica Quistgard & Jimelia Sterling 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: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

LIC809 (FAS) - (06/04)

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