342700534-4-3-2024-59-AS-KHOS-D46NEH-20240409102358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700534
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:08:42 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
03/20/2024 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20240320144631

FACILITY NAME:	SPLENDOR OF CARMICHAEL AT KEANE, THE		FACILITY NUMBER:	342700534
ADMINISTRATOR:	WILLIAMS, MARIA		FACILITY TYPE:	740
ADDRESS:	4921 KEANE DRIVE		TELEPHONE:	(916) 514-9173
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 5	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Maria Williams		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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On 4/3/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Maria Williams, 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.

On 3/20/24, the Department received an incident report, completed by Alex Tellez, that stated, “ On Wed. March 20 at 6:48 AM (crossed out) around 7 AM, (S1), employee called Martha to notify her that (R1) had a fall…”
The department received a staff statement there was a tall, male person brought in for overnight coverage and that person found R1 on the floor and bleeding. That male person assisted S1 in getting R1 back to bed.
S1 stated that they were alerted to R1 having had a fall at approximately 6:30 AM on 3/20/24.
S1 stated that they did in fact call to Martha Tufo regarding the incident and that Martha requested S1 not call 911 until Martha could arrive to assess R1. Martha told LPA that Martha directed S1 to call 911 while Martha was on the way to the home.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240320144631

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: 04/03/2024

NARRATIVE

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R1 was also taking blood thinners, had sustained a laceration and had what S1 described as “bled a lot”. The department received a Metro Fire report that showed they dispatched emergency responders at 7:16 AM and arrived at scene at 7:22. R1 reported left leg pain to responders. Family of R1 stated that R1 sustained a broken hip that required surgery.

Therefore, with apparent serious injury to R1, caregivers failed to call 911 urgently and 911 was not called until another staff arrived to assess the situation.

The circumstances of the other adult who was said to be present at the time of the fall will be addressed further in a additional report.

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.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility.

As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Report reviewed with Administrator. Copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240320144631

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: 04/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/04/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis …	1 2 3 4 5 6 7	Licensee will submit a copy of the emergency response policy as well as a plan to provide training with all employees prior to their work in the home. The POC is due by 4/4/24. Policy, training plan and 7 day schedule to be submitted.
	8 9 10 11 12 13 14	This requirement was not met based on interviews and records that there was a delay in emergency care for R1. This posed an immediate health risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

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