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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:55:56 PM


Document Has Been Signed on 06/23/2022 03:55 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:PADUA ASSISTED LIVINGFACILITY NUMBER:
342700651
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:7019 MCGILL COURTTELEPHONE:
(916) 647-3483
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
06/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rosario Reyes, CaregiverTIME COMPLETED:
04:10 PM
NARRATIVE
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On 06/23/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident report submitted to CCLD on 04/06/2022. LPA spoke with Caregiver, Rosario Reyes and explained the purpose of the visit.

Based on incident report on 04/06/2022 around 3:00 AM , Resident #1 (R1) was found lying on the floor and screaming. Staff found R1 in the hallway in between his room and bathroom lying down on the floor. R1 complained of hip hurting. Staff called 911, Licensee, Administrator, conservator, and R1's family member. R1's hip was severely injured.

Based on Staff #1 (S1) interview, R1 was going to the bathroom. R1 tripped over foley catheter and was found on the floor screaming. S1 called 911, Licensee, and Conservator and R1 was sent to the Emergency Room at Kaiser Hospital. R1 was diagnosed with a fractured femur and went into surgery on 04/12/2022. S1 stated the facility purchased a call button to assist R1 with going to the bathroom. Based on documentation, R1's Physician Report (LIC 602) was updated. However, LPA observed R1's and needs and service plan was last updated 12/15/2019.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.



Exit interview conducted with Caregiver. A copy of report and Appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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Document Has Been Signed on 06/23/2022 03:55 PM - It Cannot Be Edited

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: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited

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87705(c)(5)(A)...(A)When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes ...
This requirement was not met as evidence by:
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Based on LPA observation, licensee did not comply with section cited in 87705(c)(5)(A). LPA observed R1 does not have an updated needs and service plan on file which poses a potential health and safety risks to residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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