342700552-4-16-2021-27-AS-MSEY-C25V5V-20210416160832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700552
Report Date: 04/16/2021
Date Signed: 04/16/2021 11:22:27 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
08/20/2020 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200820130522

FACILITY NAME:	EDEN'S HOME CARE RCFE		FACILITY NUMBER:	342700552
ADMINISTRATOR:	ROOT, LINDZIE MARIE		FACILITY TYPE:	740
ADDRESS:	5917 KIFISIA WAY		TELEPHONE:	(916) 524-1280
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Suzanne Thomas		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide care and supervision necessary to meet residents' needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Department reviewed resident records, facility records and conducted extensive interviews.
The Department finds that the allegations cited above are substantiated.

On 7/24/20, hospital records note that R1 arrived at an area hospital emergency department with a chief complaint of rib pain as a result of a fall. CT scan of R1 found fractures to R1’s nose. Additionally, R1 was found to have a urinary tract infection (UTI), bruised ribs and possible concussion.

Caregiver S1 stated that on 7/24/20 she was cooking breakfast when R1’s bed alarm sounded. S1 stated that they responded immediately and approached the bathroom “within ten seconds” of the alarm. The incident report submitted by the facility stated that staff ran to assist R1 and interview statement was that S1 walked to assist R1. In those ten seconds, R1 had gotten out of bed, left their room, entered the bathroom adjacent to

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: 04/16/2021

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.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 27-AS-20200820130522

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: EDEN'S HOME CARE RCFE	FACILITY NUMBER: 342700552
	VISIT DATE: 04/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

their room, begun to disrobe, slipped and fell in their own urine. Care notes state that R1 had removed their depends before entering the bathroom.

Additional facility staff (S3) interviewed stated that R1 was a slow walker and S4 stated that R1could not walk without her walker and a guide next to her. Staff (S2, S3, S4, S5) reported that though there was not a specific fall prevention plan, they escorted R1 to the bathroom, assisted them with disrobing and waited outside the bathroom until R1 stated they were done. Staff (S2) also stated that at the time of the fall, R1’s bed alarm was not functioning. Investigators were unable to verify the functioning of the bed alarm as R1 was deceased prior to this investigation and belongings removed.

Records review conducted found: LIC 602, dated 12/24/19, for R1. Report notes ambulatory, Dementia diagnosis with behavioral disturbance, wears glasses, diabetes, hypertension, major depressive disorder and "bad knees & sometimes back". LIC 603- Pre-placement appraisal on 2/1/20. Notes: wears glasses, fall risk- uses walker and “maybe Does not use walker”, confusion and depression, is able to ambulate without physical assist, feeble and slow (has walker but does not use it), diabetic diet, wears briefs. LIC 625, dated 2/3/20. Notes: "in good health other than dementia", "functioning pretty independently".

S1 stated that R1 is known to be a fall risk and has had this type of slip and fall incident previously. S1 stated that though R1 had regular falls, resident was not reassessed nor was R1’s needs and services plan updated. S1 stated that following the 7/24/20 fall with injuries, a bathroom carpet was placed in the bathroom. Facility staff notes state that R1 did not return to their baseline for ambulation until 7/30/20.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by statements and records that S1 failed to provide assistance with activities of

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20200820130522

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: EDEN'S HOME CARE RCFE	FACILITY NUMBER: 342700552
	VISIT DATE: 04/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This posed an immediate risk to R1.

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(f). At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
08/20/2020 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200820130522

FACILITY NAME:	EDEN'S HOME CARE RCFE		FACILITY NUMBER:	342700552
ADMINISTRATOR:	ROOT, LINDZIE MARIE		FACILITY TYPE:	740
ADDRESS:	5917 KIFISIA WAY		TELEPHONE:	(916) 524-1280
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Suzanne Thomas		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged resident's medications.
Staff did not provide food of the quality to meet resident's needs.
Facility has pests.
Questionable death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.

On 8/23/20 LPA conducted a tele-inspection with Admin Lyndzie Root for an inspection of the facility and observation of residents in care. Additionally, the Department conducted records review and extensive in person interviews of staff and residents.

We are unable to find and/or meet the preponderance, per policy.

Records and statements reviewed did not meet the preponderance for findings regarding staff contribution to the death of R1 on 8/4/21. Though the facility is to be cited for failure to provide timely medical attention to R1 on 7/10/21 and 8/4/20, the death certificate listed R1’s death as natural.

Records received and statements from staff do not support the allegations of medications administered to residents without a prescription.

Unsubstantiated

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: 04/16/2021

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.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 27-AS-20200820130522

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: EDEN'S HOME CARE RCFE	FACILITY NUMBER: 342700552
	VISIT DATE: 04/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Inspections and statements from residents do not corroborate the allegation that food served does not meet regulation requirements.

Biting insects were not observed, and residents were unable to report if there were passed incidents of being bitten by insects.

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.

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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20200820130522

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: 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 CCR 87464(f)	1 2 3 4 5 6 7	Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by statements and records that S1 failed to provide assistance with activities of	1 2 3 4 5 6 7	Licensee will submit a statement of undertsanding of this requirement as well as a plan for review/ update as needed of all resident care plans for clear caregiver responsiblities for care. The plan will designate plan review/ updates to be completed by 4/23/21.
	8 9 10 11 12 13 14	daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This posed an immediate risk to R1.	8 9 10 11 12 13 14	This statement and plan to be submitted to CCL by fax by the POC date of 4/19/21. 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.
	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: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6