342700589-11-19-2021-27-AS-CVAO-C8X5FD-20211119185455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 11/19/2021
Date Signed: 11/19/2021 06:55:13 PM

Document Has Been Signed on 11/19/2021 06:55 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SKYE LUIS CARE HOME		FACILITY NUMBER:	342700589
ADMINISTRATOR:	RODRIGUEZ, ANNIE LYN		FACILITY TYPE:	740
ADDRESS:	8705 GREAT CT		TELEPHONE:	(916) 914-5119
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6		CENSUS: 3	DATE:	11/19/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	05:40 PM
MET WITH:	Annie Rodriguez		TIME COMPLETED:	07:00 PM

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	Licensing Program Analyst (LPA) Christina Valerio arrived on November 19^th, 2021 for an unannounced case management to follow up on a substantiated complaint investigation. LPA met with Annie Rodriguez, Representative of 5M Care LLC and stated the purpose of the visit. On April 17, 2020, the Department concluded a complaint investigation which alleged the following: Staff did not seek medical attention in a timely manner; resident (R1) sustained an unstageable pressure injury and unexplained fracture while in care. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87615(a)(1) Prohibited Health Conditions, § 87465(g) Incidental Medical and Dental Care Services. The facility did not seek medical attention timely and also retained R1 for 14 days with an unstageable pressure injury without a hospice referral from a physician nor did they request an exception from the Department. The investigation revealed that on December 6, 2019 the R1, sustained an acute comminuted and displaced proximal left tibial metaphyseal fracture (Left knee fracture) while being transferred with the assistance of staff (S1 and S2). On December 6, 2019, R1’s responsible party went to the facility and observed swelling below the left knee and contacted R1’s Primary Care Physician (PCP). R1’s responsible party and the facility was informed by the PCP, to monitor R1’s knee and see how it looks on December 9, 2019, and in the interim to use a cold compress and pain medication. No other instructions or patient care was advised by the PCP at this time. On December 13, 2019, the facilities Daily Reports indicate that R1 could not move their left leg. The facility did not seek medical attention between December 9, 2019, through December 19, 2019, after seeing increased swelling. Continues on LIC 809-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYE LUIS CARE HOME	FACILITY NUMBER: 342700589
	VISIT DATE: 11/19/2021

NARRATIVE

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...Continued from LIC 809

On December 20, 2019, the Acting Administrator was called in to observe R1’s leg and had stated the leg looked bad, as there was purple and blue bruising and a pressure sore to the right heel. On December 20, 2019, the facility called 9-1-1 and R1 was brought to the hospital via ambulance from the facility for lower left leg pain. Hospital medical records indicate upon admission, R1 was observed to have left lower leg pain from the knee down, with significant deformity and bruises. X-rays were taken of the left tibia-fibula region, which showed an acute comminuted and displaced proximal tibial fracture. The facility Daily Reports from December 6, 2019 through December 20, 2019 never indicate staff observing any bruises on her left leg, just that R1 had pain in her left leg.

Hospital medical records from December 20, 2019, also indicated R1 was admitted to the hospital with unstageable pressure injuries on the right heel and several stage 2 pressure injuries on the coccyx, left heel, left foot outer lateral, left leg, and upper back. The facility’s Daily Reports indicated that staff used Vaseline on R1’s heels and buttock on December 11, 2019 and December 16, 2019. There was no mention in the Daily Reports of any change in the skin integrity of R1. The facility notes do not mention observation of any pressure injuries from December 6, 2019, until R1 was hospitalized. It was determined through an interview with the Acting Administrator on January 15, 2019, that the Acting Administrator observed a pressure sore to the right heel on December 20, 2019.

Based on observation, interview, and record review, the licensee did not obtain timely medical attention which resulted in R1 being diagnosed with an acute comminuted and displaced proximal tibial metaphyseal fracture and pressure injuries that required hospitalization, which is a serious bodily injury. The licensee’s failure to seek timely emergent care caused the resident to suffer serious bodily injury.

At the time of the complaint visit on April 17, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYE LUIS CARE HOME	FACILITY NUMBER: 342700589
	VISIT DATE: 11/19/2021

NARRATIVE

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...Continued from Page 2 of LIC 809 - C

The Department has concluded an analysis and has determined that a civil penalty is warranted for the serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today November 19th, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on April 17, 2021 the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to facility representative Annie Rodriguez and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Annie Rodriguez's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC809 (FAS) - (06/04)

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