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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700534
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:17:30 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
02/14/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240214102446
FACILITY NAME:SPLENDOR OF CARMICHAEL AT KEANE, THEFACILITY NUMBER:
342700534
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:4921 KEANE DRIVETELEPHONE:
(916) 514-9173
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Maria WilliamsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents are not provided proper meals
Residents are not provided adequate showers
Facility is unsanitary
INVESTIGATION FINDINGS:
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On 4/25/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to the administrator to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

LPA conducted interviews with a prior resident who transferred from the home, their responsible party and the responsible parties for three additional residents. The resident and all family members reported that they observed meals that did not follow the facility’s sample menu of nutritious, balanced meals and at times there was a lack of knowledge and food staples in the home in early February 2024. This particularly occurred when S1 was working as the sole caregiver. On one occasion, a family member arrived at the home and their father had not had breakfast. When the family member attempted to prepare a bagel for R2, the family member found moldy bagels. On another occasion, R2 called a family member who was scheduled to visit a resident and asked the family member to buy bread for the facility.
report continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 5
Control Number 59-AS-20240214102446
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: SPLENDOR OF CARMICHAEL AT KEANE, THE
FACILITY NUMBER: 342700534
VISIT DATE: 04/25/2024
NARRATIVE
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Family and resident also reported incidents of trash not being emptied in resident rooms, floors not regularly swept or mopped and on one occasion a resident’s incontinent garment and wipes put on the floor before picked up in a trashbag and the floor then not cleaned.
A resident reported that due to one staff being busy, the resident was incontinent and experienced a delay in care and a shower.
The licensee stated that there are generally 2 staff on per shift. However, family observed often one staff only who was responsible for all resident care. The register of facility residents dated 2/22/24 recorded 6 residents 2/1/24-2/8/24- all residents were non-ambulatory and required staff assist with activities of daily living.
S1 no longer worked at the facility and was unable to be interviewed.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Admin . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240214102446
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: SPLENDOR OF CARMICHAEL AT KEANE, THE
FACILITY NUMBER: 342700534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/09/2024
Section Cited
CCR
87555(a)
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General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances...this requirement was not met based on interviews. Posed a potential risk.
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Licensee will submit meal plans which meet resident needs and reasonable wishes, three weeks list of foods actually served and food purchase receipts for that period.
The plan of correction (POC)is due 5/9/24.
Request Denied
Type B
05/09/2024
Section Cited
CCR
87464(f)(4)
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Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing … This reuirement was not met based on interviews. this posed a potential risk to residents
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Licensee will submit actual staff schedules for 2/25/24- 5/9/24 and well as the specific care needs of residents in care during that period by the POC date of 5/9/24.
Request Denied
Type B
05/09/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met based on interviews. This posed a risk to residents
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Licensee will submit a list of the cleaning and sanitizing duties that staff are responsible for, documentation of training for those duties and how often the duties will be performed.
The POC is due by 5/9/24
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/14/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240214102446

FACILITY NAME:SPLENDOR OF CARMICHAEL AT KEANE, THEFACILITY NUMBER:
342700534
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:4921 KEANE DRIVETELEPHONE:
(916) 514-9173
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained injury due to staff's negligence
Staff are not properly trained
Facility is not observing resident's change in condition
INVESTIGATION FINDINGS:
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On 4/25/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

File review and interviews found that on 12/3/23, S1 had a fall with injuries. The staff (S3) assisting with the shower of R1 was found to have recorded required staff training. The incident report noted R1 having tripped. R1 reported that R3 did not follow R1’s assistance plan causing R1 to fall. S3 was no longer working at the facility and was unable to be interviewed. Therefore the preponderance of evidence was not met.
report continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 5
Control Number 59-AS-20240214102446
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: SPLENDOR OF CARMICHAEL AT KEANE, THE
FACILITY NUMBER: 342700534
VISIT DATE: 04/25/2024
NARRATIVE
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The records review and interviews found a general occurrence of minimal staffing, however, incidents of residents not being observed for change of condition were not found during this investigation.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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.

Exit interview with administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5