342700587-2-26-2021-27-AS-KHOS-BYQKMF-20210302070127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700587
Report Date: 02/24/2021
Date Signed: 02/26/2021 09:17:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2020 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20200102145447

FACILITY NAME:	SIGNATURE LIVING ON LAVELLI WAY		FACILITY NUMBER:	342700587
ADMINISTRATOR:	ENERO, EDGAR		FACILITY TYPE:	740
ADDRESS:	10125 LAVELLI WAY		TELEPHONE:	(916) 812-0944
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 5	DATE:	02/24/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Edgar Enero		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident developed multiple wounds due to neglect
Staff not providing hygiene care

INVESTIGATION FINDINGS:

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An unannounced complaint visit was conducted via telephone due to COVID precautionary measures on February 24, 2021. Licensing Program Analyst (LPA) Lund talked to Administrator Edgar Enero and explained the reason for the call.
Current census 0 clients.

The purpose of this visit was to complete the investigation and present findings to the Administrator Edgar Enero, regarding the allegation that “Resident developed multiple wounds due to neglect & Staff not providing hygiene care.”

During the course of the investigation, LPA conducted interviews with staff, witnesses and reviewed records of the Home Health agency. Resident (R1) was seen by the Home Health agency at a facility on 12/7/19, 12/18/19, 12/20/19, and 12/27/19 to treat resident’s Stage 2 pressure injuries. Last available Home Health records were on 12/27/19 indicating resident had a Stage 2 pressure injuries. The facility followed the Home Health agencies plan of care and R1 was sent to the hospital on 12/31/19 due to R1 decline in health. R1 passed away at the hospital on 1/3/20.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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 27-AS-20200102145447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SIGNATURE LIVING ON LAVELLI WAY	FACILITY NUMBER: 342700587
	VISIT DATE: 02/24/2021

NARRATIVE

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During the course of the investigation, LPA conducted interviews with staff, witnesses and reviewed records of the Home Health agency. Based on information gathered it was unclear if resident injuries were due to lack of care or medical decline.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of 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. There were no deficiencies observed or cited at this time.

An exit interview was conducted with Administrator Enero and a copy of this report was provided via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC9099 (FAS) - (06/04)

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