342700722-1-16-2025-27-AS-SRIN-DEGRV9-20250305122106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700722
Report Date: 01/16/2025
Date Signed: 01/16/2025 06:24:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20241007094603

FACILITY NAME:	WELLQUEST OF ELK GROVE		FACILITY NUMBER:	342700722
ADMINISTRATOR:	CUEVAS, ELANA		FACILITY TYPE:	740
ADDRESS:	8871 E STOCKTON BLVD		TELEPHONE:	(916) 689-1000
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	170	CENSUS: 115	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Elena Cuevas		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Lack of care and supervision resulted in resident death.

INVESTIGATION FINDINGS:

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On 1/16/2025, at 1:50pm, Licensing Program Analyst (LPA) arrived unannounced at this facility to conduct a follow up complaint visit and deliver findings regarding the allegation noted above. LPA met with Elena Cuevas, Administrator/Executive Director (AD), and stated the purpose of this visit.

On 10/7/2024, a complaint was filed with the Department alleging that lack of care and supervision resulted in resident death. Throughout the investigation, the Department conducted interviews of relevant parties including facility staff and staff from outside agencies. Additionally, the Department reviewed relevant records to include staff statements, resident files, video footage of the incident and reports from outside agencies.

Staff interviews revealed several key factors contributing to the incident. In the interview conducted with the administrator, it was learned that the facility had a COVID outbreak on 10/2/24, which impacted the supervision of R1 as staff were implementing additional health and safety measures to mitigate the spread of COVID, which resulted in slower resident checks.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 4

Control Number 27-AS-20241007094603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/16/2025

NARRATIVE

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The administrator stated that R1 was checked every two hours but walked outside to the courtyard around 1:30 PM on 10/2/2024. Morning caregiver S1 checked on R1 twice, providing water, but did not complete a shift crossover with the afternoon staff due to a meeting. R1 was last seen conscious but was found unconscious by afternoon caregiver S3, who attempted to cool R1 down before calling 911.

2 of 3 staff interviews revealed concerns of staffing shortages. S1 later expressed regret, acknowledging the incident could have been prevented with better judgment and that they felt the facility was short staffed. S4 also mentioned that they felt the facility is short staffed and there have been past complaints by families regarding the facility being short staffed and not having staff available which negatively impacted the level of care residents received.

According to S4, they noticed R1 outside but did not notify staff or complete a shift crossover due to the meeting. After the meeting, S4 found R1 unconscious and helped with cooling measures.

S4 also felt that the facility was extremely short on staff that negatively impacted care. According to interview, S3 was assigned to R1 in the afternoon, found R1 unconscious and moved R1 to the shade. S3 felt unfairly blamed for the incident due to communication failures and under staffing. S3 also noted that front desk person could have seen R1 on the video surveillance. S3 added that other staff had seen R1 outside earlier that day but took no action to ensure R1 was safe. Interviews revealed that facility management conducted their internal investigation and has determined to terminate S3 for the incident. Administrator stated that R1’s was not purposely neglected and that the incident was a result of a huge oversight from care staff. Administrator also stated that facility has added intervention techniques to avoid future incidents from occurring.

Review of the video surveillance footage obtained from the facility cameras dated 10/2/2024 showed R1 was sitting in a patio chair in the courtyard at approximately 1:26 PM, with their body exposed to sunlight. At 1:38 PM, staff member (S1) briefly interacted with R1 for 20 seconds. Another staff member (S2) passed by R1 at 1:46 PM but did not stop. At 1:53 PM, S1 gave R1 a cup of water and stayed with R1 for about 10 seconds. At 1:59 PM, R1 was still exposed to full sunlight. Over the next hour, several residents walked past R1, and at 2:57 PM, R1 slumped over completely and was no longer visible in the chair. Afternoon staff member (S3) checked on R1 at 3:20 PM, and with assistance from another staff member (S4) and other staff, they brought R1 inside at 3:25 PM. Emergency Medical Services (EMS) arrived at 3:31 PM, and by 3:44 PM, they departed with R1 for medical care.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20241007094603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/16/2025

NARRATIVE

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Review of R1’s medical record obtained from the hospital on 10/29/2024 showed that on 10/2/2024, R1 arrived at the hospital with a core temperature of 105.3 degrees Fahrenheit with a chief complaint of altered consciousness. It was also noted that R1 had 23% to 25 % of first and second degree burns on the right forearm, foot, face, and abdomen. R1 was also diagnosed with heat stroke. On 10/3/2024, R1 had a seizure and was noted to remained comatose off sedation. It was also noted that R1’s burns began to blister. On 10/4/2024, R1 experienced fourth seizure and remained comatose. On 10/5/2024, R1 remained comatose and on comfort care. R1 later passed away on 10/62024.

Review of R1’s death report confirmed heat stroke as one of the causes of R1’s death. It was also noted that R1’s injuries occurred due to direct sunlight and elevated environmental temperature exposure.

Additionally, it was also confirmed from AccuWeahter.com that, on 10/2/2024, the outdoor temperature in Elk Grove, CA was approximately 102 degrees Fahrenheit.

The lack of care and supervision resulted in R1’s prolonged exposure to extreme heat, causing severe injuries and subsequent death. Factors contributing to R1’s incident include procedural failures, such as the lack of a shift crossover and delayed resident checks. The preponderance of evidence standards has been met; therefore, the allegation is SUBSTANTIATED.

The following deficiencies are being cited from the California Health and Safety Code (HSC) 1569.312(e). Failure to correct the deficiencies may also result in civil penalties.

At the time of the complaint visit, an immediate civil penalty of $500 was issued, and AD was informed that an additional civil penalty was pending review and may be assessed according to Health and Safety Code § 1569.49(e). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty.

Exit interview was conducted with AD and details of the deficiencies and plan of corrections were discussed. Per discussion with AD, they implemented plans to ensure residents’ overall health, safety, and well-being are properly monitored following the incident.

A copy of this report and appeal rights were provided during this visit.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20241007094603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/16/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/17/2025 Section Cited HSC 1569.312(e):	1 2 3 4 5 6 7	Basic services requirements: Every facility required to be licensed under this chapter shall provided at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.	1 2 3 4 5 6 7	As discussed, the administrator will submit a written plan outlining the supervision of residents in care to ensure their overall health, safety, and well-being are being properly monitored. The written plan to be submitted to the Department by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by Based on record reviews and interviews, the licensee did not ensure staff provided care and supervision to R1 in which R1 was left unattended outside with direct exposure to the sun and heat, sustaining heat-related injuries and heat stroke, resulting in death. This poses an immediate health and safety risks to resident in care.	8 9 10 11 12 13 14	During this visit, adminsitrator provided a list of actions that the facility has implemented after the incident.
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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.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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