342700704-9-28-2022-25-AS-LMUZ-CJUUD4-20221003152855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700704
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:57:28 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2022 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220729103109

FACILITY NAME:	A HEARTY CARE HOME I		FACILITY NUMBER:	342700704
ADMINISTRATOR:	CLARDY, MARIA J		FACILITY TYPE:	740
ADDRESS:	5794 SPENLOW WAY		TELEPHONE:	(916) 339-6440
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2022
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Maria clardy, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Questionable death
Staff did not ensure resident used his medical equipment
Staff are not qualified to use medical equipment
Staff did not call 911
Staff did not provide adequate food service to resident
Staff did not meet resident's bathroom needs
Staff did not ensure resident used his own bed

INVESTIGATION FINDINGS:

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On September 28, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounce do deliver findings for complaint 25-AS-20220729103109t . LPA met with Maria Clardy, , administrator, and informed her the reason for the visit. Prior to the visit, LPA completed required COVID-19 testing Protpcols, and a daily self -screening questionnaire and completed a facilitty risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore PPE.
The Department received a complaint alleging the death of Resident 1 (R1) was questionable and due to neglect/lack of supervision by facility staff, resident in care passed away while in care.

R1 was hospitalized from 7/20/2022 to 7/25/2022, because due to difficulty breathing. On 7/25/2022, R1 was discharged to A Hearty Care Home I. R1 was discharged with a diagnosis of acute Hyper carbic respiratory failure. Based on documentation reviewed, the transport company left R1 at A Hearty Care Home I at 1749 hours. Interviews indicated transport staff denied seeing anything concerning at the facility.
To continue see 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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 25-AS-20220729103109

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A HEARTY CARE HOME I	FACILITY NUMBER: 342700704
	VISIT DATE: 09/28/2022

NARRATIVE

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Staff and transport personnel reported that R1 appeared to be very weak and fragile upon arrival to the facility. Transport staff did not recall if R1 had oxygen at the time of transport. Facility staff reported that R1 was weak at his baseline. R1 had oxygen but was resistant to use it when prompted by staff. Staff interviews reported that transport staff stated R1 refused oxygen during transport. Per facility staff, R1 refused oxygen once he arrived back to A Hearty Care Home I on 07/25/2022.

Staff reported when R1 returned from the hospital on 07/25/2022, R1 seemed weak, but that R1 normally seemed weak. Staff attended to R1, then left to assist another client. Staff reported that R1's family arrived after 6pm on 07/25/2022. R1's family found R1 non-responsive and called 9-1-1. Staff reported that the time between leaving R1 in his room to assist the other resident, and the family arriving to find R1 unresponsive was between 15-30 minutes.

The death certificate documents R1's cause of death as respiratory arrest (onset of immediate), and advanced pulmonary fibrosis (onset of years). Other significant conditions contributing to but not resulting in the underlying cause are listed as hypertension, type 2 diabetes, melotus coronary artery disease. No autopsy was performed.

Based on Staff reported they left R1 to assist the other client about 15-30 minutes before R1's family arrived, staff were not aware R1 was unresponsive until family arrived and found R1

Staff were not aware that R1 was unresponsive and therefore did not have an indication that 9-1-1 was needed. The Department has investigated the allegations that the death was questionable and due to neglect/lack of supervision by facility staff, resident in care passed away while in care to be UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.
An exit interview was conducted and a copy of this report was given to Maria

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC9099 (FAS) - (06/04)

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