342700370-5-5-2021-27-AS-TORZ-C2WUFA-20210511153225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700370
Report Date: 05/05/2021
Date Signed: 05/05/2021 11:40:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210112124044

FACILITY NAME:	PRAIRIE CITY LANDING		FACILITY NUMBER:	342700370
ADMINISTRATOR:	MARTIN, CHERYL K		FACILITY TYPE:	740
ADDRESS:	645 WILLARD DR		TELEPHONE:	(916) 458-0303
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	200	CENSUS: 121	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cheryl Martin (Admin)		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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The facility failed to seek timely medical attention.
Resident's injury was not reported in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility on 05/05/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 01/12/2021 which alleged that The facility failed to seek timely medical attention, and Resident's injury was not reported in a timely manner. LPA spoke with Executive Director (ED) Cheryl Martin and explained the purpose of the visit.

Through the course of the investigation process, CCL conducted interviews, virtually toured the facility, and reviewed records regarding the allegations above. Interviews were conducted with Staff, Witnesses, R1’s family as well as the Executive Director (ED) Cheryl Martin. It was noted that 1/5/2021 staff notified med tech of R1 being in pain, and a large bruise to R1’s chest. R1 reported running into a door. Staff faxed R1’s doctor regarding the incident, but did not seek additional medical attention nor notify the Responsible Party (RP). R1’s doctor replied to apply ice and monitor, stating if the injury worsened it would need to be evaluated. Staff applied ice and monitored. R1 was sent out to the hospital 1/7/2021.
CONT on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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 27-AS-20210112124044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRAIRIE CITY LANDING	FACILITY NUMBER: 342700370
	VISIT DATE: 05/05/2021

NARRATIVE

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Exit interview conducted with Cheryl Martin (Admin). LPA provided admin with a signed copy of the report, along with the 9099-D. Appeal rights provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 27-AS-20210112124044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRAIRIE CITY LANDING	FACILITY NUMBER: 342700370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/06/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the 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 was not met as evidence by:	1 2 3 4 5 6 7	Cheryl Martin agrees to provide CCL of a statement of understanding stating ED has reviewed Title 22, Division 6; Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right: 87466.
	8 9 10 11 12 13 14	Based on the facilities documentation and staff interviews; there was no indication that the facility completed any monitoring as instructed by the doctor. As a result the facility did not ensure proper observation of the resident. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/06/2021 Section Cited CCR 87211(a)(1)(B)	1 2 3 4 5 6 7	Reporting Requirements (a) Each licensee shall furnish... (1) A written report... to the licensing agency and to the person responsible... within seven days of... (B) Any serious injury... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Cheryl Martin agrees to provide CCL of a statement of understanding stating ED has reviewed Title 22, Division 6; Chapter 8, Article 04. Operating Requirements: 87211(a)(1)(B). ED agrees to provide print outs to all supervisors who submit incident reports to CCL.
	8 9 10 11 12 13 14	Facility submitting the documentation regarding R1’s incidents between nine (9) and eleven (11) days after they occurred.	8 9 10 11 12 13 14

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210112124044

FACILITY NAME:	PRAIRIE CITY LANDING		FACILITY NUMBER:	342700370
ADMINISTRATOR:	MARTIN, CHERYL K		FACILITY TYPE:	740
ADDRESS:	645 WILLARD DR		TELEPHONE:	(916) 458-0303
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	200	CENSUS:	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cheryl Martin (Admin)		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident's room was not cleaned
Resident's clothing was not cleaned

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility on 05/04/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 01/12/2021. LPA spoke with Executive Director (ED) Cheryl Martin and explained the purpose of the visit.

Through the course of the investigation process, CCL conducted interviews, virtually toured the facility, and reviewed records regarding the allegations above. Interviews were conducted with Staff, Witnesses, R1’s family as well as the Executive Director (ED) Cheryl Martin. It was noted that 1/5/2021 staff notified med tech of R1 being in pain, and a large bruise to R1’s left chest. Staff faxed R1’s doctor regarding the incident, but did not seek additional medical attention nor notify the Responsible Party. R1’s doctor replied stating to apply ice and monitor, stating if the injury worsened it would need to be evaluated. Staff applied ice and monitored. R1 returned to the hospital 1/7/2021. In an interview conducted with the ED, Cheryl reported that R1 may have had a fall, and in hindsight they should have sent him out to the ER sooner.
CONT.LIC9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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 27-AS-20210112124044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRAIRIE CITY LANDING	FACILITY NUMBER: 342700370
	VISIT DATE: 05/05/2021

NARRATIVE

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Community Care Licensing Division (CCLD) received notification on 1/18/2021, of the 1/7/2021, and 1/9/2021, incidents. The Executive Director Cheryl Martin reported that the 1/7/2021, incident was faxed to CCLD on 1/14/2021, and the 1/9/2021, incident was faxed to CCLD on 1/15/2021. The incident reports did not indicate that bruising was initially noted on 1/5/2021. An interview conducted with ED indicated that after the 1/5/2021, incident, RP and CCLD should have been notified immediately.

During a virtual tour of the facility upon opening the complaint on 1/21/2021, LPA Leitzell viewed R1’s room and noted it had been cleaned prior to the tour. An interview with the ED conducted indicated that the room was cleaned twenty-four (24) hours after R1 went out to the hospital. Between that time, R1’s family came to gather belongings, viewing a room that had vomit on the carpets and some of R1’s clothing. ED stated the family has a right to be upset, and the room should have been cleaned in a timely manner.

Due to this information CCL finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Technical Assistance being assessed.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210112124044

FACILITY NAME:	PRAIRIE CITY LANDING		FACILITY NUMBER:	342700370
ADMINISTRATOR:	MARTIN, CHERYL K		FACILITY TYPE:	740
ADDRESS:	645 WILLARD DR		TELEPHONE:	(916) 458-0303
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	200	CENSUS:	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cheryl Martin (Admin)		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained a fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility on 05/04/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 01/12/2021. LPA spoke with Executive Director (ED) Cheryl Martin and explained the purpose of the visit.

Through the course of the investigation process, CCL conducted interviews and reviewed records regarding the allegation. Based on interviews conducted and reports reviewed, it is unknown how R1 sustained the clavicle fracture. R1 was not a fall risk and was able to change his own clothing and shower on his own, but staff would be present for stand-by assistance. Interviews conducted denied any significant mobility issues for R1. Furthermore, the x-ray of R1’s shoulder area was taken 1/7/2021 which did not reveal any fracture. A later CT scan performed on 1/9/2021 revealed a fracture to R1's clavicle.

Cont. LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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 27-AS-20210112124044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRAIRIE CITY LANDING	FACILITY NUMBER: 342700370
	VISIT DATE: 05/05/2021

NARRATIVE

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CCL finds the allegation of Resident Sustained a Fracture while in care to be UNSUBSTANTIATED. A finding that the 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. Although there is proof to say that R1 sustained a fracture, there is insufficient evidence to suggest neglect or lack of supervision are at fault.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7