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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700828
Report Date: 10/24/2024
Date Signed: 10/24/2024 05:32:00 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
04/18/2024 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20240418141213
FACILITY NAME:LOVE AND SERENITY OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR:CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff on duty (S1)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff are not following facility procedures for resident falls.
INVESTIGATION FINDINGS:
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On 10/24/24, at 2:30pm, Licensng Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with staff on duty (S1) and stated the purpose of the visit.

Allegation: Facility staff are not following facility procedures for resident falls.

Throughout this investigation, LPA conducted interviews and record reviews of relevant documents. On 4/25/24, LPA Villanueva interviewed staff member S1, who confirmed that resident R1 was hospitalized on 4/18/24 due to a fall and change in behavior. S1 expressed uncertainty about whether incident reports had been submitted to the Department and noted that he sometimes writes these reports without knowledge of their follow-up. On 8/14/24, S1 detailed the procedures followed when a resident falls, which include assessing the resident, calling 911 if injured, and assisting them back to a chair if uninjured.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 5
Control Number 27-AS-20240418141213
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: LOVE AND SERENITY OF ELK GROVE III
FACILITY NUMBER: 342700828
VISIT DATE: 10/24/2024
NARRATIVE
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A review of incident reports revealed multiple falls involving R1. On 11/15/23, R1 fell after lunch, hitting their forehead. The incident was unwitnessed, and Alpha One was notified. On 2/22/24, R1 fell while attempting to reach the dining room; it was unclear if the fall was witnessed. Staff found R1 on the floor, and Alpha One was called. On 4/18/24, R1 experienced two falls in one day. These falls were witnessed by outside agency visiting that day. Additionally, R1 was displaying combative behavior not typical of their baseline which prompted facility staff to send R1 to emergency hospital. Staff were present, yet no preventive measures were documented post-incident. Note that additional incidents of falls involving other residents in care were reviewed, specifically those dated 7/17/24, 5/28/24, 12/10/23, 11/12/23, and 10/18/23.

Review of the facility's policies and procedures, provided by Administrator Bianca Castro, outline actions to take after a fall occurs but fail to include proactive measures to prevent falls. The document emphasizes the need for timely medical care but does not address risk mitigation strategies. There is a clear gap in compliance with the expectation that facilities develop and implement a fall prevention plan, especially for high-risk residents like R1, who was assessed as a fall risk.

Resident R1 was noted to have several risk factors, including: abnormal gait and mobility; non-ambulatory status, requiring the use of a front-wheel walker; and history of a medical condition (C1), which may contribute to instability. Despite these factors being documented, there is no evidence that staff are following a systematic approach to monitor or mitigate these risks, further substantiating the allegation of non-compliance.

As a result of the investigation, the preponderance of evidence standards has been met, therefore, the allegation that facility staff are not following facility procedures for resident falls was SUBSTANTIATED due to the absence of a fall prevention plan and the documented incidents highlighting the facility’s lack of proactive measures to prevent future falls.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. LPA discussed Plan of Correction with Administrator and gave permission to S1 to sign this report.

Exit interview was conducted with S1 and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240418141213
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: LOVE AND SERENITY OF ELK GROVE III
FACILITY NUMBER: 342700828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87464(d)
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87464(d) Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...
This requirement is not met as evidenced by:
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Per discussion with Licensee, she will generate a fall prevention plan for all residents identified as fall risk and submit plan to the Department by POC due date.
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Based on interviews and record reviews, facility did not initiate a fall prevention measures after R1’s multiple fall incidents. This posed a potential health and safety risk to residents in care.
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Licensee to train staff on fall prevention plan and submit proof of training to the Department by POC due date.
CCR
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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: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/18/2024 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20240418141213

FACILITY NAME:LOVE AND SERENITY OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR:CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff on duty (S1)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff are not administering medications as prescribed by doctor.
INVESTIGATION FINDINGS:
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On 10/24/24, at 2:30pm, Licensng Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with staff on duty (S1) and stated the purpose of the visit. Present during today's visit were 4 residents in care with 1 staff on duty (S1). Administrator was not able to come to the facilty and gave permission to S1 to sign this report.

The investigation into the allegation that facility staff are not administering medications as prescribed by doctor for Resident 1 (R1) consisted of interviews and record reviews of relevant documents. The review included R1's physician orders and medication records dated February 27, 2024, which detailed several relevant PRN medications. Medication1 (M1) 50 mg was prescribed to be taken at bedtime as needed for insomnia, with the prescription written on October 2, 2023. Additionally, M2 10 mg was prescribed to be taken twice daily as needed for agitation, with the order issued on February 21, 2024. Notably, R1 began taking M1 50 mg routinely at bedtime starting February 21, 2024, along with M3 3 mg as needed.

Con't to LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 5
Control Number 27-AS-20240418141213
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: LOVE AND SERENITY OF ELK GROVE III
FACILITY NUMBER: 342700828
VISIT DATE: 10/24/2024
NARRATIVE
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Upon reviewing R1’s Medication Administration Record from September 2022 to June 2024, LPA found that staff were administering R1's medications as prescribed. While the PRN Authorization Letter dated February 26, 2024, was incomplete—lacking a physician's signature and not clearly indicating R1's ability to communicate their needs—the overall administration of medications followed the prescribed guidelines. Staff member (S1) confirmed that R1 could express their needs regarding PRN medications, particularly for sleep. For the M1, it was noted that the dosage varied between one and two tablets, in line with the prescription allowing for this flexibility.

Despite some oversights, such as the lack of documentation indicating that the physician or nurse was consulted before administering PRN medications, the actual administration of R1's medications, including M3 and M1, was consistent with the prescribed orders. For M2, multiple administrations were documented, reflecting adherence to the prescription aimed at managing R1's agitation. Although there are concerns regarding the thoroughness of documentation and communication with healthcare providers, the evidence does not have preponderance of evidence that the allegation that staff are not administering medications as prescribed by doctor. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview was conducted with S1 and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5