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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700763
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:08:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
10/04/2022 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221004170100
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert TifTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff does not ensure resident has an assigned PCP.
INVESTIGATION FINDINGS:
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On 4/19/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met Robert Tif. Prior to initiating the complaint visit, LPA completed the Department's COVID-19 precautions.

LPA reviewed resident records, facility records and conducted interviews.
LPA finds that the allegations cited above are substantiated.

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

Report continued
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 25-AS-20221004170100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
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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, the 2015 physician’s report stated that, “will need to find a primary care physician in the community.” Also on file was R1’s Identification and Emergency Information dated 11/29/15 which listed a physician who had previously treated R1 but had retired. During R1’s stay at the facility, the licensee did not assist R1 with obtaining a primary care physician.

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 9099-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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221004170100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87465(a)(1)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Licensee agrees to submit a statement of understanding of this regulation by the POC date of 5/17/23.
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 This requirement was not met as evidenced by records and statements. This posed a potential 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
10/04/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20221004170100

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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert TifTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
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Staff does not ensure resident is taking prescribed medications.
Resident fell while in care.
Staff did not ensure resident is being repositioned.
Staff did not have proper training to transfer resident.
Staff did not provide resident with eviction notice.
INVESTIGATION FINDINGS:
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On 4/19/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with licenseef. Prior to initiating the complaint visit, LPA completed the Department's COVID-19 precautions. LPA wore a Surgical Mask.

On 10/14/22, LPA Cassie Yang collected records and conducted and interview.
On 1/25/23, LPA Kevin Mknelly conducted and 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

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Report continued
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20221004170100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
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Staff does not ensure resident is taking prescribed medications- As R1 did not have a primary care physician while a resident at this facility, R1 also had no prescribed medication. Statements from the licensee and staff were that in 2014-2015 R1 was prescribed medications for agitation and anxiety. Statements also were that as R1 adjusted to the facility that he was in at the time, those medications were discontinued. R1 was admitted to this facility with no medications nor medication orders.

Resident fell while in care- R1 was noted in records to have a fall history. On 9/24/22, R1 had a recorded fall for which R1 was transported to an area hospital for evaluation. Statements provided did not find that the fall occurred due to staff actions or inactions.

Staff did not ensure resident is being repositioned- While R1 has significant motor disfunction and left hemi-paresis, R1 was able to reposition independently. Records did not indicate R1 had experienced skin breakdowns while at the facility. R1’s bed was equipped with ¼ bed rails and trapeze bar.

Staff did not have proper training to transfer resident- Licensee had general training on file. Other staff training was not present at the facility during inspection. Records from skilled nursing did not indicate R1 required specialized transfer.

Staff did not provide resident with eviction notice- R1 was not evicted. Statements obtained were that at the time of R1’s 9/24/22 hospitalization, the licensee and R1’s power of attorney (POA) voiced concerns regarding R1’s physical decline and a need for a higher level of care. As a result, R1 was transferred to rehabilitation where he remained for the duration of this investigation. POA stated that it was his request that an alternative placement be pursued and that R1 would not return to this facility.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 25-AS-20221004170100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
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During the course of this investigation, additional deficiencies were found and cited on a separate report.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with licensee.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 6