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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700552
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:59:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:EDEN'S HOME CARE RCFEFACILITY NUMBER:
342700552
ADMINISTRATOR:ROOT, LINDZIE MARIEFACILITY TYPE:
740
ADDRESS:5917 KIFISIA WAYTELEPHONE:
(916) 524-1280
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Suzanne ThomasTIME COMPLETED:
10:30 AM
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On 4/16/21, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Suzanne Thomas, Licensee of facility Eden’s Home Care at approximately 9:30 AM by Web Ex meeting. Also present on the call was LPA Angela Hood. LPAs were unable to meet at the facility due to current circumstances.

The purpose of this report is to issue citations for violations found during the investigation of complaint control number 27-AS-20200820130522. The Department conducted the investigation between 8/22/20 and 3/11/21. In addition to the findings of the complaint investigation, the department also found that R1 was not provided timely medical care on multiple occasions, licensee did not conduct criminal record clearance, personnel records or training for S2, the Administrator failed to report incidents as required and they failed to fulfill their Administrator duties.

On 7/10/20, S1 noted in R1 care notes that blood was observed on soiled sheets. S1 requested R1’s responsible party contact the primary care physician for a UTI test and antibiotics if confirmed. Though there were continued care notes for the need for the test, none was performed. On 7/24/20 when R1 had a fall with injuries, they were also found to have a UTI.

Following R1’s fall and injuries on 7/24/20, care notes indicate R1 was recovering from their injuries and on 7/30/20 was able to get out of bed unassisted. In care notes 7/24-8/3/20 R1 was not observed as having shortness of breath.

Continued.

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

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
VISIT DATE: 04/16/2021
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On 8/3/20, S1 care notes note R1 not feeling well and mostly sleeping. There is no note of R1’s physician having been contacted for this change of condition.

Based on the investigation, the following citation will be issued for violating California Code of Regulation (CCR) Title 22, 87465 (g) incidental Medical and Dental Care: 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. On 8/4/20, S1 care notes state that while assisting R1 to the bathroom R1 got “really short of breath”. When R1 caught their breath, S1 assisted them back to bed. S1 contacted R1’s daughter to report the incident and suggest the daughter get Oxygen from R1’s palliative care services. There is no note of R1’s physician having been contacted for this change of condition., Staff, S2, who worked at the facility on 8/4/20 until 2 PM, stated that when they left, R1 was showing no signs of respiratory symptoms. S2 also stated that S1 had stated to emergency personnel that R1 had fallen on 8/4/20 which caused their shortness of breath. S1 denied R1 fell on 8/4/20 to investigators. S1’s notes stated that “an hour later”, while S1 assisted R1, R1 complained of rib pain. Ibuprofen was provided by S1. R1 requested S1 assist with repositioning. When assisted, R1s shortness of breath resumed. S1 phoned 9-1-1 at 6:45 PM. R1 was deceased at 6:50 PM when emergency responders arrived. A relative of the licensee reported that S1 had told him that R1 was heard gurgling and gasping for air” before 9-1-1 was called. Further evidence discovered indicates that on 8/3/20, S1 care notes report that R1 was not feeling well and was mostly sleeping. Based on the documentation found in the case notes it was discovered there was no record of R1’s physician being contacted for their change of condition. As a result, based on the failure of S1 to obtain timely medical attention for R1, or resulting hospitalization, and these circumstances lead to the resident’s death.

87411(g) Personnel Requirements - General (g)(1) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This

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

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
VISIT DATE: 04/16/2021
NARRATIVE
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requirement was not met as evidenced by statements and records which find S2 was not fingerprinted prior to working at the facility and a relative of licensee stated, on 9/11/20 phone call with LPA Mknelly, they are a 10% owner and staff statements indicate he routinely is at the facility to deliver paychecks and do routine maintenance. This poses an immediate risk to residents.

An immediate civil penalty in the amount of $500.00 is to be assessed for each of the two staff known to have worked without required clearance in excess of 5 days.

87411 Personnel Requirements - General (f) All personnel, … shall be in good health… verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement was not met as evidenced by there was no health screen/ Tb completed for S2. This posed a potential risk to residents.

Staff records 87412 (a) Personnel Records- The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee…This requirement was not met as evidenced by statements and S1 was unable to produce a file for S2. This posed a potential risk to residents.

Training 87705 ( c ) (3) 87705 Care of Persons with Dementia-( c) (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned… this requirement was not met as evidenced by a lack of record and a statement by S1 that S2 refused training. This posed a potential risk to residents.



Reporting requirements 87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident …This requirement was not met at evidenced by statement
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
VISIT DATE: 04/16/2021
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and records where S1 failed to report fall by R1 on 5/14/20 in which she sustained injury and was taken to emergency department for evaluation. This posed a potential risk to residents.

Reappraisal 87463(a) Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by statements by S1 and records that R1 had a change of condition for falls not previously addressed in their 2/3/20 needs and services plan. This posed a potential risk to R1.




87405(d) (2) Administrator- Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met by Administrator Lyndzie Root (S1) as evidenced by failure to provide care and supervision, failure to report incidents, failure to hire, train, screen staff and maintain files for employees and failure to provide timely medical care to R1. This posed an immediate risk to residents.


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.

Unable to obtain signature. Signature present on hard copy in file. LPA sent a copy of report for Licensee, Suzanne Thomas to sign. Licensee to send a signed copy back to CCL.


Additionally, LPA sent a copy of the appeal rights.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2021
Section Cited

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 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. This requirement was not met
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As evidenced by records and statements that R1 demonstrated a medical emegency for which 9-1-1 call was delayed. This posed an immediate risk to the resident.
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Type A
04/19/2021
Section Cited

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 Personnel Requirements - General (g)(1) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement was not met
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 as evidenced by statements and records which find S2 was not fingerprinted prior to working at the facility and a relative of licensee statements indicate he routinely is at the facility to deliver paychecks and do routine maintenance. This poses an immediate risk to residents.
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Civil Penalties applied.
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: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2021
Section Cited

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Administrator- Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met by Administrator Lyndzie Root (S1) as evidenced by failure to provide care and supervision, failure to report incidents, failure to hire, train, screen staff and maintain files for employees and failure to provide timely medical care to R1. This posed an immediate risk to residents.
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maintain files for employees and failure to provide timely medical care to R1. This posed an immediate risk to residents.
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Statement with plan to be submitted to CCL by POC date of 4/19/21
Type B
04/30/2021
Section Cited

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Personnel Requirements - General (f) All personnel, … shall be in good health… verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement was not met as evidenced by there was no health screen/ Tb completed for S2. This posed a potential risk to residents.
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health screen/ Tb completed for S2. This posed a potential risk to residents.
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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: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EDEN'S HOME CARE RCFE
FACILITY NUMBER: 342700552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited

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Staff records 87412 (a) Personnel Records- The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee…This requirement was not met as evidenced by statements and S1 was unable to produce a file for S2. This posed a potential risk to residents.
Type B
04/30/2021
Section Cited

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87705 Care of Persons with Dementia-( c) (3)... staff who provide direct care to residents with dementia shall receive... training as appropriate for the job assigned… this requirement was not met as evidenced by ecord and a statement S2 refused training. This posed a potential risk to residents.
Type B
04/30/2021
Section Cited

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 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident …This requirement was not met at evidenced by statement and records where S1 failed to report fall by R1 on 5/14/20 in which she sustained injury. This posed a potential risk to residents.
Type B
04/30/2021
Section Cited

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Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by statements and records that R1 had a change of condition without reappraisal. This posed a potential risk to R1.
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: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7