342700670-10-27-2020-27-AS-KHOS-BV2Q3U-20201104104919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700670
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:40:24 PM

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
03/12/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200312091745

FACILITY NAME:	LATER YEARS SENIOR CARE HOME		FACILITY NUMBER:	342700670
ADMINISTRATOR:	ORNELLAS, MARITES		FACILITY TYPE:	740
ADDRESS:	14 ARARAT CT		TELEPHONE:	(916) 538-6096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 5	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marites Ornellas		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff failed to observe resident's change in condition
Facility staff did not meet the hygiene needs of resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced complaint visit. This tele-visit using Microsoft Teams on10/27/2020 at 12:30pm was conducted due to COVID-19 and pre-cautionary measures. LPA spoke with Marites Ornellas and stated the purpose of the visit which is to deliver complaint investigation findings.

LPA received and reviewed the following documents from the Licensee regarding Resident #1 (R1): Admission Agreement, Physician Report, ID and Emergency Information, Centrally Stored Medication Log, Medication Administration Record (MAR), Appraisal and Needs Service Plan, Resident Appraisal, pictures of R1’s room and the facility bathroom. LPA received and reviewed medical records regarding R1 from the local hospital for dates 2/1/2020 through 4/1/2020. LPA also received and reviewed medical records regarding R1 from the Home Health Agency for dates 2/10/2020 through 3/9/2020.

Unfounded

Estimated Days of Completion: 90+

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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A review of R1’s medical records from the local hospital indicate the Administrator was contacting the Primary Care Physician (PCP) for an updated Physician Report (LIC602). A review of R1’s facility records indicate R1 moved into the facility on 2/10/20. Additionally, the medical records indicate that R1 was seen by a licensed skilled professional on 2/14-16/2020 at which time home health was ordered for intermittent skilled nursing care such as physical therapy, and speech therapy. R1 was also seen on February 19, 20, 24, 26, 27, 28 and March 2, 7, and 9 by the licensed skilled professionals. On 3/7/20, licensed skilled professionals documented that R1 was diagnosed with “gluteal cleft region shows likely stage II ulcers with no infection and healing well.”

The investigation revealed that although pressure injuries developed while in care, the facility and responsible party together obtained medical attention. The facility provided observation, care and supervision of R1.

Regarding the allegation, “Facility staff did not meet the hygiene needs of resident”, LPA obtained through an interview the Home Health RN stated that the facility staff followed her instructions and the pressure injuries were healing. The hospital medical records revealed that on 3/7/20 licensed skilled professionals observed the pressure injuries to be healing well. The facility staff documented on Care Notes that R1 was receiving assistance in repositioning every 2 hours. The pressure injuries were noted as being present from 2/25/20 – 3/7/20 during this time the licensed skilled professional at the local hospital and Home Health RN both concur that the pressure injuries were at a stage 2 and healing well. There was no mention in either of the medical records that there was concern for the residents’ body odor or hygiene care of the resident. Staff stated that R1 was taken to the bathroom as often as agreed to by R1 and there were not 3 diapers put on R1. Staff agreed that inside of the diaper there was additional padding used to hold the amount of urination that R1 would excrete. This method was agreed upon by the responsible party who provided the materials for staff to use for that purpose. R1 was changed every 2 hours according to the interviews conducted with S1, S2, S5, S6 and Licensee.

The investigation revealed that although R1 sustained stage 2 pressure injuries the hygiene needs were met as there was no records indicating the needs were not met.

The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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“This agency has investigated the complaint alleging, the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

An exit interview was conducted with Marites Ornellas via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 10

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
03/12/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200312091745

FACILITY NAME:	LATER YEARS SENIOR CARE HOME		FACILITY NUMBER:	342700670
ADMINISTRATOR:	ORNELLAS, MARITES		FACILITY TYPE:	740
ADDRESS:	14 ARARAT CT		TELEPHONE:	(916) 538-6096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 5	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marites Ornellas		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident is left unattended for an extended period of time-uns
Facility staff are not providing assistance to residents in care in a timely manner-uns
Facility is not providing adequate activities for residents in care-uns
Facility staff did not inform resident's authorized representative of changes in their condition-uns
Facility staff restricted resident's water intake-uns

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced complaint visit. This tele-visit using Facetime on x/x/2020 at 00:00am was conducted due to COVID-19 and pre-cautionary measures. LPA spoke with Marites Ornellas and stated the purpose of the visit which is to deliver complaint investigation findings.

LPA received and reviewed the following documents from the Licensee regarding Resident #1 (R1): Admission Agreement, Physician Report, ID and Emergency Information, Centrally Stored Medication Log, Medication Administration Record (MAR), Appraisal and Needs Service Plan, Resident Appraisal, pictures of R1’s room and the facility bathroom. LPA received and reviewed medical records regarding R1 from the local hospital for dates 2/1/2020 through 4/1/2020. LPA also received and reviewed medical records regarding R1 from the Home Health Agency for dates 2/10/2020 through 3/9/2020.

Unsubstantiated

Estimated Days of Completion: 90+

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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Regarding the allegation, “Resident is left unattended for an extended period of time”, the investigation revealed S1 stated that staff would put residents in the restroom and be on the backside of the door. S2 stated that R1 would not be left alone too long. S4 stated staff would stand beside the resident and not leave them alone. The S6 stated most of the time the staff would stand around the corner next to a wall from the toilet that is inside the bathroom. The Licensee stated staff stands right on the other side of the wall of the bathroom to talk to them and does not walk away. LPA observed pictures of the bathroom used with R1. The pictures show that the bathroom has a quarter wall separating the toilet from the bathroom door.

There is no preponderance of evidence that the staff would be outside of the bathroom but will be on the other side of the quartered wall to provide the resident privacy while using the restroom. Based on the interviews and a review of the pictures of the bathroom the preponderance of evidence standards has not been met.

Regarding the allegation, “Facility staff are not providing assistance to residents in care in a timely manner”, Staff stated that R1 would be resistant to assistance without the presence of the responsible party. It was alleged that R1 would be found wearing 3 diapers with a pad in between on several occasions. LPA observed in the medical records from the local hospital that R1 was observed by Licensed Skilled Professional(s) and deemed to be incontinent with large amounts of urine. On 2/14/20, R1 was seen by the emergency department who mentioned on the medical record that R1 was incontinent of urine and a brief was in place. S1 indicated that R1 urinated a lot. S1 stated the facility staff follows a routine every day which includes the night shift. The routine they follow is that after meals, staff would ask the residents if they want to go use the restroom or staff would change the diapers. S2 stated that all the caregivers do the same thing. S5 stated R1 was changed every 2 hours. S6 stated the only time the diaper may have not been changed is on a trip to the Dr and not while in the facility, R1 was always changed every 2 hrs. S6 also stated that the responsible party may not have been made aware but R1 would also remove the diaper and urinate all over the room. A review of the facility Daily Notes indicate that staff documented R1 was assisted with incontinence every 2 hours. There was no mention in the medical records from the local hospital that R1 had hygiene issues upon arrival. In addition, the Home Health notes did not reveal that R1 was not receiving hygiene care from the facility staff.
The investigation revealed that staff did use additional padding along with the diapers for R1 at the suggestion of responsible party who provided the padding for staff to use.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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Regarding the allegation, “Facility is not providing adequate activities for residents in care”, the investigation revealed that R1 would participate in a ball activity on occasion. LPA obtained through interviews that R1 participated in a ball activity with a visitor in the presence of the responsible party. According to the facility staff, R1 would participate sometimes but not always. There was no mention in Daily Notes that staff provided activities. The daily notes did, however, mention R1 went on a walk with the responsible party twice within a 6-day period. The Licensee stated that R1 watched videos, looked at pictures on her phone as a guess who game, walked and played catch with the ball. Licensee stated that all residents would be asked if they wanted to participate, it was mostly their decision which would depend on their night before. Usually the residents would tell them what they felt like doing at the time. R1 would walk and talk with a visitor, once the visitor would leave, and the responsible party would arrive to walk R1 again. Staff advised that R1 may be tired from walking already and may want to sleep.

The investigation revealed that activities were offered and made available. If R1 or other residents prefers not to participate or want to do something else, the staff can not violate their personal rights.

In regards to the allegation, “Facility staff did not inform residents authorized representative of changes in their condition”, Staff indicated during interviews that the responsible party(s) were present daily and assisted in the care of R1 with the exception of the first 3 days given to R1 to become acclimated to the new residence. The Administrator stated that the responsible party was always informed by staff and visiting nurses in person and or by phone. The facility Care Notes indicated that between 2/18/2020 to 2/23/2020 there were no skin changes. Staff #1 (S1) stated R1 had redness on the sacral area and an ointment was being used as a barrier as instructed by the Home Health RN on 2/19/20. During a visit on 2/25/2020, the home health RN observed a pressure injury on R1’s sacral area at which time she began applying barrier cream. She stated that within 2 weeks of working with R1 the area was a stage 2. On 2/27/20, the home health records indicated that the authorized representative arrived during an evaluation and was pleased with the assistance from home health. S2 stated there was redness but there were no sores. The care notes also indicated the staff were turning R1 as instructed by the home health RN. The RN also confirmed that staff was following her instructions with the care of the resident. She stated that if the instructions were not followed the pressure injuries would have gotten worse.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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The investigation revealed that on 3/7/20, Medical Records noted that R1 is having more “bedsores” and there is concern of infection. The records further indicate that the pressure injuries appear to be stage II and there is no sign of infection. Throughout the emergency room, hospital and doctor appointments, LPA observed that R1’s representative was present for each including home health visit.

In regards to the allegation, “Facility staff restricted water intake”, LPA interviewed staff and requested and received a photo of the cup that was purchased by the Administrator for the use of R1. The photo of the blue plastic cup with a matching straw indicates that it is a 24oz cup. The Licensee and staff all concur that this cup was used for R1.

LPA observed in the medical records from the local hospital that R1 was observed by Licensed Skilled Professional(s) and deemed to be incontinent with large amounts of urine. On 2/14/20, the records indicate unrestricted regular diet. S1 indicated that R1 urinated a lot. S5 stated R1 was changed every 2 hours. S6 stated the only time the diaper may have not been changed is on a trip to the Dr and not while in the facility, R1 was always changed every 2 hrs. S6 also stated that the R1 would remove the diaper and urinate all over the room. A review of the facility Daily Notes indicate that staff documented R1 was assisted with incontinence every 2 hours. Upon a further review of the local hospital medical records, LPA did not observe any mention of dehydration or instructions to increase fluids for R1.

The preponderance of evidence standards was not met. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted with Marites Ornellas via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 7 of 10

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
03/12/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200312091745

FACILITY NAME:	LATER YEARS SENIOR CARE HOME		FACILITY NUMBER:	342700670
ADMINISTRATOR:	ORNELLAS, MARITES		FACILITY TYPE:	740
ADDRESS:	14 ARARAT CT		TELEPHONE:	(916) 538-6096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 5	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marites Ornellas		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility screen is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced on a subsequent complaint visit. This tele-visit using Facetime on x/x/2020 at 00:00am was conducted due to COVID-19 and pre-cautionary measures. LPA spoke with Marites Ornellas and stated the purpose of the visit which is to deliver complaint investigation findings. LPA received and reviewed the following documents from the Licensee regarding Resident #1 (R1): Admission Agreement, Physician Report, ID and Emergency Information, Centrally Stored Medication Log, Medication Administration Record (MAR), Appraisal and Needs Service Plan, Resident Appraisal, pictures of R1’s room and the facility bathroom. LPA received and reviewed medical records regarding R1 from the local hospital for dates 2/1/2020 through 4/1/2020. LPA also received and reviewed medical records regarding R1 from the Home Health Agency for dates 2/10/2020 through 3/9/2020.

Substantiated

Estimated Days of Completion: 90+

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 10/27/2020

NARRATIVE

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In regards to the allegation, “Facility screen is in disrepair”, LPA requested and received a picture of the room window where R1 resided. LPA interviewed the Licensee who concur that when R1 resided in the room the contractor was told that the window was missing a screen. The Licensee also provided a copy of the documentation that was given to the contractor requesting the screen be replaced. According to the Licensee the representative of R1 was informed of the missing screen. However, there was blinds on the window. The preponderance standards of evidence has been met, Therefore, the allegation will be cited during this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 9 of 10

Control Number 27-AS-20200312091745

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: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2020 Section Cited CCR 87303(c)	1 2 3 4 5 6 7	Maintenance and Operation All window screens shall be clean and maintained in good repair.	1 2 3 4 5 6 7	Licensee shall ensure the maintenance of the facility is such that makes the surrounding area safe for residents, employees and visitors ensuring that personal rights are not violated. POC cleared by photo
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on LPAs observations that the screen was missing from the window prior to the admittance of the resident. This violation poses a potential 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: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 10 of 10