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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:11:35 PM


Document Has Been Signed on 04/19/2023 02:11 PM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:A-1 ELDERLY CAREFACILITY NUMBER:
342700763
ADMINISTRATOR:TIF, ROBERTFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVETELEPHONE:
(916) 996-4763
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
04/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert TifTIME COMPLETED:
02:30 PM
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On 4/19/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced visit to provide findings discovered during the course of a complaint investigation and met licensee. Prior to initiating the complaint visit, LPA completed the Department's COVID-19 precautions.

LPA reviewed resident records, facility records and conducted interviews during the course of a complaint investigation. These additional findings were noted.

On 10/14/22, LPA Cassie Yang collected records and conducted and interview.
On 1/25/23, LPA Kevin Mknelly conducted a further review of records and interviews.
On 2/7/23, LPA Mknelly interviewed R1 and spoke with Skilled Nursing staff.
4/18/23, LPA received Skilled nursing records.

Licensee did not have a physician’s evaluation for R1 dated within 12 months of R1’s admission to the facility. Resident file reviews found that: Facility had only a Physician’s report dated 1/28/15. Statements from the licensee found that that 1/28/15 report was from R1’s prior placement and a new report was not obtained for within 12 months of R1’s admission to this facility. Furthermore, records review of skilled nursing records found resident had prior history chronic pain and upon admission to skilled nursing was prescribed several PRN medications and a sleep aid.

Report continued
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: A-1 ELDERLY CARE
FACILITY NUMBER: 342700763
VISIT DATE: 04/19/2023
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Licensee did not have a current Appraisal/ needs and services plan though stated that R1 was declining to the point that R1 needed a higher level of care. Resident records review found a partial needs and services plan for R1 dated 4/20/21. Statements by the licensee were that they sought a higher level of care are R1’s change of condition made his care at this facility difficult. However, a new appraisal/ needs and services plan was not created to reflect the increased care needs of R1


As a result of this investigation, LPA finds allegation to be (S) 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 following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Licensee . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/19/2023 02:11 PM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: A-1 ELDERLY CARE
FACILITY NUMBER: 342700763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

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Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This requirement was not met based on records and statements. This posed a potential risk to R1.
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Licensee agrees to submit up to date physician reports for current (5) residents by the POC date of 5/17/23.
Type B
05/17/2023
Section Cited

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Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met based on records and statements. This posed a potential risk to R1
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Licensee agrees to submit up to date Appraisal/Needs and Services plans for current (5) residents by the POC date of 5/17/23.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
LIC809 (FAS) - (06/04)
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