342700758-12-29-2023-27-AS-TTRG-CYYPQH-20231229103110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700758
Report Date: 12/29/2023
Date Signed: 12/29/2023 10:31:15 AM

Document Has Been Signed on 12/29/2023 10:31 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:	LOVE AND COMFORT II		FACILITY NUMBER:	342700758
ADMINISTRATOR:	VUNIMATANA, RATU		FACILITY TYPE:	740
ADDRESS:	320 BOWMAN AVE		TELEPHONE:	(916) 832-3626
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95833
CAPACITY:	6	CENSUS: 5	DATE:	12/29/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Eliesa Quolele		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit on 12/29/2023. Upon LPAs arrival, facility staff Eliesa Quolele was present and contacted Administrator Ratu Vunimatana who advised that he is sick and is unable to come to the facility. LPA spoke with Administrator Ratu Vunimatana over the phone and explained the purpose of the visit. This visit is to deliver a civil penalty regarding “staff failing to seek timely medical attention for resident's change in condition.” Administrator gave permission for staff to sign today's report. On December 08, 2022, the Department received a complaint alleging, “staff did not seek timely medical attention for resident's change in condition.” The investigation revealed the resident (R1) began refusing food and medication in July of 2022. It was also learned the facility made two failed attempts to contact R1’s primary care physician (PCP) for the change in condition. The first PCP contact attempt was in September of 2022, and the second attempt was in October of 2022. R1 was sent to the hospital in August of 2022 and early October of 2022 for agitation although there was no mention of R1’s nutrition intake. By mid-October 2022, R1 was refusing all medication. However, facility staff did not pursue following up with R1’s PCP. Additionally, R1’s responsible party was not informed of R1’s health condition change. Hospital notes indicated R1 was diagnosed with Anorexia and depleted fat stores. R1 was also cachectic and had lost 60 pounds since March 31, 2021. At the time of the November 3, 2022, hospitalization, R1 weighed 126 pounds and their body mass index (BMI) was 21. Furthermore, medical notes reported R1 had a scaphoid abdomen, decreased fat stores, and temporal wasting. [Continued on 809-C, Page 2]

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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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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: LOVE AND COMFORT II	FACILITY NUMBER: 342700758
	VISIT DATE: 12/29/2023

NARRATIVE

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On February 07, 2023, a medical professional noted R1 was very thin with evidence of poor nutrition. It was also noted R1’s refusal of food and medication was a serious concern, and R1 should have received timely medical attention for failure to thrive. A facility staff reported on February 09, 2023, that R1 should have been transferred to a higher level of care facility before October 2022 due to health condition changes.

As a result, on March 09, 2023, the Department substantiated the allegation “staff did not seek timely medical attention for resident's change in condition” and the licensee was cited for violating the California Code of Regulations Title 22, section 87464(f)(1) Basic Services, which states, “Basic Services shall at a minimum include: care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).” The Licensee failed to obtain timely medical attention for R1 and retained R1 after acknowledging R1’s change in health condition required a higher level of care facility. This posed an immediate safety risk to R1. The licensee was informed that a civil penalty was still being determined and may be assessed based on Health and Safety Code section 1569.49.

The Department has concluded an analysis and has determined that a civil penalty per Health and Safety Code section1569.49(f), in the amount of $10,000 is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. The Welfare and Institutions Code section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery or physical rehabilitation.” This is evidenced by the licensee’s failure to ensure proper care and supervision for R1, resulting in R1 sustaining significant weight loss and hospitalization in the intensive care unit. There was a substantial risk of death or impairment of bodily function due to client refusing food and medication.

[Continued on 809-C, Page 3]

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: LOVE AND COMFORT II	FACILITY NUMBER: 342700758
	VISIT DATE: 12/29/2023

NARRATIVE

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Today, 12/29/2023, the Department will be issuing a civil penalty per Health and Safety Code section 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 09, 2023, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to Eliesa Quolele and originals were signed.

An exit interview was conducted. A copy of the report issued. Appeal rights provided. Staff Eliesa Quolele signed on this report acknowledges receipt of the appeal rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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