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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700722
Report Date: 09/04/2024
Date Signed: 09/05/2024 11:32:03 AM


Document Has Been Signed on 09/05/2024 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WELLQUEST OF ELK GROVEFACILITY NUMBER:
342700722
ADMINISTRATOR:CUEVAS, ELANAFACILITY TYPE:
740
ADDRESS:8871 E STOCKTON BLVDTELEPHONE:
(916) 689-1000
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:170CENSUS: 105DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elena CuevasTIME COMPLETED:
04:48 PM
NARRATIVE
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On 9/4/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 07/02/2024 . LPA met with Executive Director, Elena Cuevas (ED) and explained purpose of visit.

The incident report detailed an occurrence in which resident R1 was mistakenly given eye drops intended for another resident. This error was made by a staff member on duty (S1), who promptly reported the incident as required. Note that the incident was reported to CCLD within the reporting requirement.

Upon a review of the incident report and R1's medication records, it was verified that R1 did not have a prescription for the eye drops that were mistakenly administered on June 26, 2024. During the visit, staff member (S2) provided additional details, explaining that following the incident, R1’s hospice provider was promptly notified. A skilled nurse from the hospice subsequently assessed R1’s condition. According to S2, the hospice provider did not issue further instructions but continued to monitor R1 to ensure their well-being after the error. S2 also clarified that the eye drops administered were antibiotics that had been discontinued prior to today's visit.

A comprehensive review of R1’s care notes corroborated that there were no adverse reactions or negative effects from the administration of the eye drops. Furthermore, an interview with the Executive Director (ED) and a review of the incident report revealed that S1, who was responsible for the medication error, was removed from medication duties after the incident. S1 also underwent additional training to prevent future occurrences of such errors.



Per California Code of Regulations, Title 22, deficiency is being cited during today's case management inspection. Note that failure to correct the citation can result in civil penalties.
An exit interview was conducted with Elena and a copy of this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/05/2024 11:32 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WELLQUEST OF ELK GROVE
FACILITY NUMBER: 342700722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2024
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care Services: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidenced by
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Licensee to submit a statement of understanding of the regulation cited regarding medication administration. Statment to be submitted to the Department by POC due date.
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Based on record review and interview, licensee did not comply with the regulation noted above. S1 administered eye drops to R1that were prescribed for another resident. This poses a potential health, safety and personal rights risk to residents in care.
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S1 was retrained for medication administration.
Licensee to submit proof of S1's retraining to the Department by POC due date.

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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: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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