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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700758
Report Date: 03/09/2023
Date Signed: 03/09/2023 10:02:15 AM

Substantiated


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
11/03/2022 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20221103154308
FACILITY NAME:LOVE AND COMFORT IIFACILITY NUMBER:
342700758
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 6DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident sustained a fall with injuries while in care.
Staff did not provide adequate supervision to a resident.
Staff did not inform authorized reprsentative of reisdents fall in timely manner.

INVESTIGATION FINDINGS:
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On 03/09/2023 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Ratu Vunimatana during today’s visit and explained the purpose of today’s visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents. The investigation revealed resident 1 (R1) sustained an unwitnessed fall on November 02, 2023, and it was unknown how long R1 was on the floor. R1 was found on the ground and unresponsive in their room by facility staff. R1 was sent to the hospital on November 02, 2023, and while hospitalized R1 was diagnosed with a hematoma to left forehead with 2cm hemostatic laceration. It was also learned R1 had Nondisplaced recent right L1 transverse process fracture, Chronic left L2, L3 transverse process fractures. Chronic left posterior 11th rib fracture. As a result, R1 sustained a fall with injuries while at residing at this facility and was not provided adequate supervision.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 7
Control Number 27-AS-20221103154308
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: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
VISIT DATE: 03/09/2023
NARRATIVE
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The investigation also revealed that facility staff did not inform R1's responsible party (RP) of R1's fall on November 02, 2023. Furthermore, it was determined facility staff did not inform R1's RP of health condition changes. Therefore, the facility did not follow reporting requirements, and a deficiency can be found on the 9099-D page.

An immediate $500.00 civil penalty shall be assessed on March 08, 2023 for a violation of California Code of Regulations Section 87466, which based on the allegation: “Resident sustained a fall with injuries while in care” R1 sustained an un-witnessed fall with injuries and was hospitalized, which this posed an immediate threat to the Health, Safety, and Personal Rights of R1.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments per Health and Safety Code 1569.49(e). At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

As a result of this investigation, the Department finds This allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiency cited can be found on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
11/03/2022 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20221103154308

FACILITY NAME:LOVE AND COMFORT IIFACILITY NUMBER:
342700758
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 6DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not provide adequate foods to resident resulting in severe malnutrition.
INVESTIGATION FINDINGS:
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On 03/09/2023 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Ratu Vunimatana during today’s visit and explained the purpose of today’s visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents. It was learned the facility was providing food to R1. However, R1 was refusing to eat the meals that facility was providing. As a result, there is not a preponderance of evidence to prove that facility was not providing adequate food. Please refer to complaint 27-AS-20221208150500 to review allegation: "Staff did not seek timely medical attention for resident's change in condition."


Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20221103154308
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: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
VISIT DATE: 03/09/2023
NARRATIVE
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During the Department's investigation, it was learned the facility did not seek timely medical condition in regards to R1 refusing to eat. Moreover, facility citation can be found on complaint 27-AS-20221208150500 report.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20221103154308
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: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
87466
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87466 Observation of the resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided...This requirement was not met as evidence by:
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Facility staff agree to conduct resident check ins and document check-in by POC date 030/10/2023, In addition to training all staff in regards basic care and supervision. The facility staff agrees to email LPA Martinez a written plan in regards to training and how resident check in will be implemented.
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Based on interviews, record reviews, medical document reviews, the Licensee did not ensure R1 was provided care supervision an received medical attention when R1 had a change in health condition. This posed an immediate health and safety risk to R1.
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 by POC Date 03/10/2023 by 5 PM.
All training material and sign in sheet shall be emailed to LPA Martinez by POC Date 03/23/2023 by 5 PM.
Type A
03/09/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities 87468.1 (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful, and comfortable accommodations furnishings and equipment. This requirement was not met as evidence by:
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Facility staff agree to conduct Personal rights training for all staff. The facility staff agrees to email LPA Martinez a written plan in regards to training and how the facility will implement personal rights policy at the facility.
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Based on interviews and file reviews, the Licensee did not ensure R1 was accorded a safe and healthful and comfortable accommodations. As R1 sustained injuries from an unwitnessed and it was unknown how long R1 was on the ground. This posed an immediate health and safety risk to R1.
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 by POC Date 03/10/2023 by 5 PM.
All training material and sign in sheet shall be emailed to LPA Martinez by POC Date 03/23/2023 by 5 PM.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 27-AS-20221103154308
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: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited
CCR
87211(a)(1)
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Reporting Requirements 87211(a) (1) Each licensee shall furnish to the licensing agency such reports as the Department may require.. A written report shall be submitted to the licensing agency and to the person responsible ...This requirment was not met as evidence by:
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Facility staff agree to conduct reporting requirement training for all staff. All training material and sign in sheet shall be emailed to LPA Martinez by POC Date 03/23/2023 by 5 PM. The licensee also adjusted care staff schedules and at every shift there are now two staff working.
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Based on interviews, and file review, The licensee did not ensure all reporting requirments was met, as the facility staff did report health changes to R1' RP. This posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7