342700843-2-22-2023-27-AS-KHOS-CPFR3N-20230227114013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700843
Report Date: 02/22/2023
Date Signed: 02/22/2023 04:59:03 PM

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
08/02/2022 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20220802140801

FACILITY NAME:	PADUA ASSISTED LIVING 2		FACILITY NUMBER:	342700843
ADMINISTRATOR:	DAYOAN, ANGELITA		FACILITY TYPE:	740
ADDRESS:	2929 BABSON DRIVE		TELEPHONE:	(279) 333-7621
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 3	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	DAYOAN, ANGELITA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not meet resident's needs
Staff did not safeguard resident's personal belongings
Staff denied to provide resident's authorized representative with a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by .

The investigation was conducted by the Department. The investigation consisted of interviews with staff, interviews with witnesses, review of resident medical reports, facility chart notes and facility resident files.

The Department has determined the following as it relates to the allegations: Staff did not meet resident's needs, Staff did not safeguard resident's personal belongings, and Staff denied to provide resident's authorized representative with a refund

Continued on LIC 9099 - C...
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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-20220802140801

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: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
	VISIT DATE: 02/22/2023

NARRATIVE

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On 2/7/2023 LPA Ivey Canady interviewed S1 regarding the care services provided by the facility to R1. S1 stated the primary caregiver for R1 was S2. On 2/7/2023 LPA Ivey Canady interviewed S2 regarding the care provided by the facility and S2 purported not to be in the facility during the 3-4 days that R1 was at the facility, and purported not to be active in R1's care. According to the interview with S2, S2 was also away at a doctor's appointment when emergency personnel were called to the facility regarding R1. On 2/7/2023 S1 gave testimony that most of the calls received from R1's family regarding the status of R1, had to be rerouted back to the facility because S1 was not present at the facility. According to witness statements, S3 told R1's family that R1 had been fed a spaghetti dinner. However, based on interviews from S1, R1 had begun to decline and remained unconscious from the beginning of R1's arrival to the facility. Furthermore, S1 stated S2 had given R1 the spaghetti dinner, however testimony from S2 is that S2 was never in the presence of R1. Therefore, the allegations Staff did not meet residents’ needs is Substantiated.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

On 8/12/2022 LPA Ivey Canady interviewed S1 regarding the status of R1's personal belongings. According to the interview with S1, the caregivers at the facility take out all belongings and annotate belongings on official LIC form. LPA requested copy of form. LPA did not receive a copy of the form. Based on interview with S1, the beginning of the interview with S1, there is a 2 day wait to put away belongings. Further along in the same interview, S1 made a correction and said belongings are put away immediately. On 2/7/2023, LPA requested the status of R1's left over personal belongings. S1 stated those particular belongings were never at the facility. However, according to interviews with witnesses, the belongings in question were left at the facility when R1 was taken by ambulance to the hospital. Based on interviews with S1, R1 had been fed particular meals. However, R1 would have not been able to be fed those particular meals without belongings that S1 stated was never at the facility. Therefore the allegation Staff did not safeguard resident's personal belongings is Substantiated.
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Cont on 9099-C
Page 2 of 3
Exit interview held, report given to Administrator

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 27-AS-20220802140801

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: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	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 was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated there will be staff training regarding resident observation and will submit training sign in sheet to LPA no later thatn 5pm 2/23/2023
	8 9 10 11 12 13 14	According to interviews with staff, the Licensee did not ensure R1 was appropriately monitored during the stay at the facility. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 02/22/2023 Section Cited CCR 87217(b	1 2 3 4 5 6 7	87217(b) Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted...This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated there will be a receipt system created whereas resident's families will sign acknowledging that belongings are received. Licensee will send a copy of the receipt system no later than 3/22/2023
	8 9 10 11 12 13 14	Based on interviews with Staff and Witness, the Licensee did not ensure R1 belongings were secured as directed by Title 22 Regulations. This poses a potential health and safety risk for persons in care	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 27-AS-20220802140801

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: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/22/2023 Section Cited CCR 87507(5)(A)	1 2 3 4 5 6 7	87507(5)(A)Admission Agreements (5) Refund conditions.(A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death...This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated there will be staff training regarding providing refunds. Licensee will send a copy of staff sign in sheet vi.a email to LPA no later than 3/22/2023
	8 9 10 11 12 13 14	According to interviews, Licensee did not ensure R1 family received refund as described in facility Admission Agreement. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 27-AS-20220802140801

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: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
	VISIT DATE: 02/22/2023

NARRATIVE

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On 2/7/2023 LPA Jamie Ivey Canady interviewed Staff 1 (S1) regarding current allegations. According to interview with S1, refund to R1's family was submitted and processed on 9/30/2022. According to interview with witness several attempts were made to secure a refund from the facility after the death of R1. Based on record review, refund was not made within 5 business days of R1 death as in accordance with facility admission agreement signed on 7/9/2022. Therefore, the allegation Staff denied to provide resident's authorized representative with a refund is Substantiated
Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 7 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
08/02/2022 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20220802140801

FACILITY NAME:	PADUA ASSISTED LIVING 2		FACILITY NUMBER:	342700843
ADMINISTRATOR:	DAYOAN, ANGELITA		FACILITY TYPE:	740
ADDRESS:	2929 BABSON DRIVE		TELEPHONE:	(279) 333-7621
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 3	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	DAYOAN, ANGELITA		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff denied resident phone calls

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 27-AS-20220802140801

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: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
	VISIT DATE: 02/22/2023

NARRATIVE

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On 1/20/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed R1 family witness regarding current allegations. On 2/7/2023 LPA Ivey Canady interviewed S1 regarding current allegations. According to interviews, there were many calls regarding the welfare of R1. During the calls the status of R1 was consistently asked. Based on interviews, many calls were placed to facility licensee cell number. According to interviews, there were times the phone calls to the cell phone were routed to the facility land line to get a real time status of the condition of R1. According to interviews with witness and S1, the question to speak directly to R1 was not asked. Therefore, the allegation Staff denied resident phone calls is Unsubstantiated.
An unsubstantiated finding means 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, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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