342700535-11-17-2021-25-AS-MSEY-C8VTHA-20211118134422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700535
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:00:32 PM

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
04/16/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210416152203

FACILITY NAME:	SPLENDOR OF CARMICHAEL AT PALM, THE		FACILITY NUMBER:	342700535
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	2839 CALIFORNIA AVE		TELEPHONE:	(916) 514-9421
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 4	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Maria Williams, House Manager/Assistant Administrator and Bruce Foggy, Administrator		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Resident left unattended led to injuries
Staff failed to call 911 after resident sustained fall with injuries
Facility not reporting incidents to Community Care Licensing Division

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint the Department received on 4/16/2021. LPA met with Maria WIlliams, House Manager, who contacted Administrator, Bruce Foggy, and explained purpose of inspection. LPA discussed complaint findings with Bruce Foggy, Administrator,who arrived shortly to the facility, and House Manager. House Manager confirmed there are (4) residents present and there are currently no residents receiving hospice services. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the course of the investigation, the Department interviewed the Administrator, House Manager, (3) caregivers, (3) residents, resident's (R1)representative and attempted to interview (2) additional caregivers. Additionally, the Department reviewed documentation pertaining to resident (R1) including, but not limited to, physician's report, appraisal, Needs and Services plan, Admission Agreement, hospitall discharge notes, facility charting notes, Unusual Incident/Injury Report (LIC624), 9-1-1 incident report, voice message audios (2), hospital and other documentation.

The results of the investigation are as follows:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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 25-AS-20210416152203

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: SPLENDOR OF CARMICHAEL AT PALM, THE	FACILITY NUMBER: 342700535
	VISIT DATE: 11/17/2021

NARRATIVE

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Allegation: Resident left unattended led to injuries.

Resident's (R1) physician's report, dated 9/8/2020, indicates that resident was not able to care for her own toileting needs and the Needs and Services Plan, dated 9/7/2020, notes that resident "has difficulty walking" due to recovering from a hip replacement. Resident's Admission Agreement signed on 9/7/2020, notes that resident would receive continuous care and supervision and assistance with toileting and with mobility tasks.

Assistant Administrator, Maria, stated that R1 had a tendency to get up on her own without using her walker and sometimes the caregivers would discover that resident's walker had been moved in her room, knowing that she got up on her own. Maria stated that resident preferred to do things on her own. Interviews revealed that while Maria was bathing another resident, caregiver, Irene, left R1 alone in the bathroom so she could attend to another resident who was requesting assistance and when the caregiver returned to R1's room, she found resident on the floor with a bump and possibly blood on her forehead.

Additionally, House Manager, left a voicemail for R1's family member stating that resident had fallen after being left alone in the bathroom and had sustained a bump on her head and the skin was open a little. Review of the LIC624 notes that resident was found in her room on the floor on 10/8/2020 and resident's daughter and the Administrator were notified. Further, resident charting notes completed on 10/8/2020 at 0700 hours, note that resident was found on the floor in the bathroom and resident's family member was called. The Department was provided with (2) audio voice messages from Maria to resident's representative on 10/8/2020 (0921 and 0929). The first message asks resident's representative to return her call, and there is no mention of a fall or injury. The second audio voice message informs resident's representative that she called previously about resident falling earlier that morning in the bathroom and resident has a bump on her head, and black eye, but she does not need any emergency medical care.

Interviews with multiple caregivers concluded that staff was aware of R1's physical limitations and her inclination to do things on her own, yet she was left alone. Interviews further revealed that staff Irene did not know how long it would take to assist the other resident and was aware that Maria was not available due to helping bathe another resident.

Based on information obtained during the investigation, the Department finds the allegation 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.

cont on 9099-C (2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 25-AS-20210416152203

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: SPLENDOR OF CARMICHAEL AT PALM, THE	FACILITY NUMBER: 342700535
	VISIT DATE: 11/17/2021

NARRATIVE

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9099-C(2)..Allegation: Staff failed to call 911 after resident sustained fall with injuries.

Facility policy is that staff will call 9-1-1- should a resident require medical attention. Based on interviews conducted with staff who were at the facility on 10/8/2020 when resident (R1) fell and facility documentation, R1 fell at 0700 hours on 10/8/2020. Review of the 9-1-1 incident report (#F20161635) shows that the facility called for medical attention for R1 at 14:27 hours.

Interview with caregiver, Irene, revealed that she did not seek medical attention earlier for R1 due to caring for other residents and Maria was caring for R1, explaining that she thought resident's daughter would know what was best for R1 once she arrived.

Assistant Administrator/Caregiver, Maria, stated that at the time she did not think that R1 needed medical attention following her fall on 10/8/2020; however, she stated when interviewed in July 2021 that she should have called 9-1-1 immediately upon finding resident on the floor and it was her mistake that 9-1-1 wasn't called earlier that day.

Interview with resident's representative indicated that she didn't receive the voice messages left by Maria on 10/8/2020 at 0921 and 0929 hours as she was getting ready for an scheduled appointment at her house at 1200 hours and wasn't looking at her phone. Resident's representative stated that she answered her phone when Maria called her again, at approximately 1230 hours, and she was told that resident did not need any emergency care even though she had a bump on her forehead and a black eye.

The Department was provided with a written statement by a witness who was with resident's representative at the time she received a phone call from Maria on 10/8/2020 at approximately 1230 hours. The statement notes that the caller indicated that resident had a fall earlier that day but resident's representative didn't need to come to the facility and the resident didn't need to go to the hospital due to the hospital not doing anything and it was risky due to potential exposure to Covid-19.

Interview with resident's physical therapist, who was treating resident in her recovery of hip surgery, revealed that when she observed resident at the facility on 10/8/2020 at approximately 1100 hours, she told Maria and resident's family member that resident needed immediate medical attention due to having a swollen eye, cut on her forehead and being incoherent and that she would call 9-1-1 if they didn't.

Based on information obtained, the Department finds the allegation 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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 25-AS-20210416152203

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: SPLENDOR OF CARMICHAEL AT PALM, THE	FACILITY NUMBER: 342700535
	VISIT DATE: 11/17/2021

NARRATIVE

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9099-C(3)..Allegation: Facility not reporting incidents to Community Care Licensing Division.

Administrator stated to LPA on 4/23/2021 that resident (R1's) fall on 10/8/2020 was previously reported; however, an LIC624 was not found in the Department's e-fax files. After LPA requested it, the Department received a completed LIC624, dated 10/8/2020, for resident's fall on 10/8/2020 by email on 4/26/2021 (2:04 pm); LPA confirmed receipt of the LIC624 by email on 4/26/2021 (2:37 pm) and requested fax documentation of when the report was initially sent to the Department, however, no documentation was provided.

During the course of the investigation, it was learned that another resident (R2) fell on 1/25/2021 at the facility and was taken to the Emergency Room by R2's family member. R2's family member indicated that the facility informed her on 1/25/2021 at approximately 1030 hours that resident had an unsupervised fall in her room.

LPA reviewed medical documentation provided to the Department showing that R2 arrived at emergency room on 1/25/2021 at 1258 hours after an unwitnesed fall, complaining of pain to her right side hip, back and leg. A LIC624 was not found in the Department's e-fax files for this incident occurring on 1/25/2021.

Based on information obtained, the Department finds the above allegation 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.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies are cited, on the 9099-D pages.

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.

Exit interview. Copy of report and appeal rights were provided to Administrator via e-mail following the inspection.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 4 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
04/16/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210416152203

FACILITY NAME:	SPLENDOR OF CARMICHAEL AT PALM, THE		FACILITY NUMBER:	342700535
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	2839 CALIFORNIA AVE		TELEPHONE:	(916) 514-9421
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS:	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Maria Williams, House Manager/Assistant Administrator and Bruce Foggy, Administrator		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Facility violated admission agreement

INVESTIGATION FINDINGS:

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During the course of the investigation, the Department interviewed Administrator, House Manager and resident's (R1) representative and reviewed resident's Admission Agreement.

The results of the investigation are as follows: Complaint states that the faciity did not bill resident's representative until three months after resident moved in and then sent a second bill after six months with interest.

Resident's (R1) Admission Agreement, dated 9/7/2020, states, in part, under "Optional Items and Services" that "any services or items that are either requested or needed by the resident, and are not listed under "Basic Services" shall incur additional charges. The resident or responsible person will be billed monthly, and receipts will be provided". Resident's representative, House Manager and Administrator confirmed that resident (R1) did not receive any additional services as listed in the Admission Agreement while residing at the facility.

Based on information obtained, the Department finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted. Copy of report was provided via email following the inspection.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 25-AS-20210416152203

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: SPLENDOR OF CARMICHAEL AT PALM, THE	FACILITY NUMBER: 342700535
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/19/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (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 and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct staff training to ensure staff standby during toileting as needed. Training documentation to be provided to the Dept by fax 11/19/2021.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was provided with the personal assistance and continuous care and supervision, as needed, with toileting, on 10/8/2020, and resident was left unattended in the bathroom, which resulted in resident falling and sustainnig injuries, which posed an immediately health and safety risk to resident in care.	8 9 10 11 12 13 14
Type A 11/19/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to review Regulation 87465 and send documentation to the Department by fax by 11/119/2021.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff called 9-1-1 timely after resident (R1) fell on 10/8/2020 @ approximately 7:00 am, which posed an immediate health and safety risk to resident in care. Review of the 9-1-1 incident report shows that the facility called for medical attention for R1 at 14:27 hours.	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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 25-AS-20210416152203

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: SPLENDOR OF CARMICHAEL AT PALM, THE	FACILITY NUMBER: 342700535
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/01/2021 Section Cited CCR 87211(a)(1)(B)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LIcensee/Administrator agree to submit a completed LIC624 to the Department by fax by 12/1/2021 for the incident occuring on 1/25/2021 when resident (R2) was sent to the ER after an unwitnessed fall. Each facility has its own fax machine as of on/around June 2021.
	8 9 10 11 12 13 14	Based interviews conducted and documentation reviewed, the Licensee did not ensure that a completed LIC624 was submitted to the Department within 7 days of resident (R1) falling on 10/8/2020 and resident (R2) falling on 1/25/2021, which posed a potential health and safety risk to resident in care.	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: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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