342700587-6-9-2023-27-AS-KHOS-CSXLCT-20230619083851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700587
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:39:08 PM

Substantiated

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
02/17/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20230217163200

FACILITY NAME:	SIGNATURE LIVING ON LAVELLI WAY		FACILITY NUMBER:	342700587
ADMINISTRATOR:	ENERO, EDGAR		FACILITY TYPE:	740
ADDRESS:	10125 LAVELLI WAY		TELEPHONE:	(916) 896-0719
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 5	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Jerome Tecson		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff neglected resident care resulting in hospitalization and death of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver the complaint findings on 6/9/2023. LPA met with Administrator Designee, Jerome Tecson and explained the purpose of the visit.

The investigation was conducted by the Department which consisted of reviews of records and interviews. Based on the interviews and records obtained during the investigation process, it was learned that resident (R1) was placed in the facility on 12/30/22 with a stage 2 pressure ulcer on the right buttocks. On 1/13/23, that same pressure ulcer developed into a stage 3 and R1 developed a new ulcer on the left buttocks which was a stage 2. On 1/27/23, R1 developed an unknown stage pressure ulcer on the penis, a new pressure ulcer on the left buttocks which was unstageable, and stage 2 pressure ulcer on the sacrum.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20230217163200

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: 06/09/2023

NARRATIVE

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Based on the information obtained during the investigation, it was determined that facility staff were not following R1’s care plan which resulted in R1 sustaining four new pressure ulcers while only living in the home for approximately one month. It was determined that the facility failed to follow licensing regulations and retained R1 in the home with a stage 3 pressure injury without an exception approval from the Department. In addition, the facility failed to notify Licensing regarding R1 change of condition and update R1’s care plan once new pressure ulcers were discovered.

As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87465. The licensee was informed that an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code 1569.49(e). Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

An exit interview was conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230217163200

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/10/2023 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall submit a plan of correction detailing how the resident’s care plan will be follow by POC due date of 6/10/2023.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not ensure that resident's care plan is being followed. Facility staff did not reposition R1 as required which led R1 to sustaining more pressure injuries. This poses an immediate health and safety risk to residents 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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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