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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700556
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:50:30 PM


Document Has Been Signed on 09/23/2022 01:50 PM - It Cannot Be Edited

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:DELA PAZ CARE HOMEFACILITY NUMBER:
342700556
ADMINISTRATOR:DELA PAZ, LOURDESFACILITY TYPE:
740
ADDRESS:6712 GREEN ASH CTTELEPHONE:
(916) 599-0477
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:4CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lourdes Dela Paz, Administrator and Dennis Abadilla, House Manager TIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident report received on 8/29/2022. LPA met with caregiver, Josephine Ilomin, and Edgardo Chico, and explained purpose of inspection. LPA met with Dennis Abadilla, House Manager and then Lourdes Dela Paz, Administrator, who arrived to the facility. Upon arrival, LPA was screened per Covid precautionary measures. Prior to the inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE): Surgical masks. LPA observed (2) clients finishing eating lunch at the kitchen table and (2) clients to be in their rooms.

LPA discussed the incident report concerning client (C1) who began to complain of leg pain on 8/4/22. House Manager stated to LPA that staff did not observe client to have any swelling or rash on 8/4/22 nd the facility Nurse Consultant also assessed client and did not see any signs of a fracture. The House Manager stated that he accompanied client to a movie the day before and client did not fall during the outing and staff indicated that client had not had any recent falls. House Manager stated that client continued to be able to use/walk with a cane as previously done and was given PRN pain medication, but the client was unable to indicate if the pain medication was helping. Client was taken to his primary care physician's (PCP) office for further evaluation on 8/17/22 to address continual pain and discomfort on both legs and recently on his thighs. Documentation reviewed shows blood tests were ordered on 8/17/22. House Manager indicated that a fracture was ruled out by PCP. Documentation shows client was seen by another physician on 8/11/22. House Manager stated that client was still able to get up on 8/26/22 but on 8/27/22, staff alerted him that client was unable to get up so was sent to ER. Discharge papers show client had a right femur fracture and had right hip surgery before being discharged on 9/10/22. House Manager and documentation shows client has other underlying medical conditions which contributed to client sustaining a fracture. Client has been recently placed on hospice on 9/10/22. LPA spoke briefly to client who was resting in his room.
Based on information obtained, it appears the facility took appropriate action in seeking further medical treatment for client. There are no deficiencies cited. Exit interview. Copy of report emailed.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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