342700886-6-20-2022-27-AS-KHOS-CG2QJ3-20220705121204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 06/20/2022
Date Signed: 06/20/2022 10:01:26 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
03/23/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220323143616

FACILITY NAME:	GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE		FACILITY NUMBER:	342700886
ADMINISTRATOR:	IRENE CHARNELL		FACILITY TYPE:	740
ADDRESS:	9750 LAGUNA SPRINGS DRIVE		TELEPHONE:	(916) 667-3167
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	70	CENSUS: 30	DATE:	06/20/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kirk Goodwin		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility didn't follow resident's care plan.
Insufficient staffing to meet the residents' needs.

INVESTIGATION FINDINGS:

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On 06/20/2022 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver findings. LPA Martinez met with Kirk Goodin and explained the purpose of the visit.

Throughout the complaint investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility files. LPA Martinez reviewed resident 0's (R0) 2022 Resident Assistance Record. This document indicated care was not completed on some days in January, February, and March. Moreover, during a facility interview, it was reported it is unknown if care was provided on various days in January, February, and March of 2022. LPA Martinez also reviewed R0's 2021 Resident Assistance Record. This document showed that care was not provided on some days in October, November, and December.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

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 4

Control Number 27-AS-20220323143616

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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE	FACILITY NUMBER: 342700886
	VISIT DATE: 06/20/2022

NARRATIVE

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LPA Martinez reviewed 01's January and February 2022 Medication Administration Record (MAR). It was determined medications were not being administered on some day in January and February. R0 Admission care plan includes providing and administering medication. As result, the facility did follow R0's care plan.

During the investigation, LPA Martinez toured the facility. It was learned the facility does not have adequate staff to meet the needs of the residents in care. LPA Martinez observed a resident activity on June 6, 2022. LPA Martinez observed one activity caregiver and 14 residents. At times an additional caregiver entered the activities room, but the caregiver did not stay and assist with the activity.

Throughout the duration of the activity, residents were eating each others snacks. Residents were also drinking each others water while the assigned activity caregiver was completing other tasks. The assigned activity caregiver had to stop her current task, and stop the residents from eating and drinking each others snacks and water. Resident 1 (R1) attempted to transfer onto a chair, and half his bottom was off the chair. The assigned activity caregiver stopped her current task to help R1. During this time, the other residents were not supervised. Resident 2 (R2) requires additional emotional support and attention. Throughout the activity, R2 continued to ask for help and asked for her hand to be held. R2's needs were not being met due to the assigned activity caregiver being busy with other tasks. LPA Pascua approached R2, and asked R2's if she needed any assistance.

Additionally, resident 3 (R3) was sitting at the outside patio unsupervised. R3 was sitting on a wheelchair directly under the sun. LPA Martinez observed R3 from the activity room at 11:02 AM. LPA Martinez did not observer any care staff check on R3. At 11:13 AM, R3 woke up and pushed himself to the activity exterior room door. Residents tried to open the door for R3. Once the assigned activity caregiver became aware of this incident, the assigned activity caregiver stopped her current task to open the door for R3. The assigned activity caregiver did not offer R3 a snack or drink. In addition, the assigned activity caregiver did not encourage R3 to participate in the activity.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20220323143616

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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE	FACILITY NUMBER: 342700886
	VISIT DATE: 06/20/2022

NARRATIVE

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R3 wandered off into the facility common area. During this time, resident 4 (R4) 02 nasal tubing was not on correctly, and LPA Martinez had to inform the assigned activity caregiver to assist R4. The assigned activity caregiver stopped her current task to help R4. The activity ended at 11:30AM and ambulatory residents were escorted to the dinning room. The following four non-ambulatory residents had to wait for other caregivers to assist them to the dinning room:

Resident 5 (R5) was assisted at 11:35 AM.
Resident 2 (R2) was assisted at 11:38 AM.
Residents 6 and 7 (R6/R7) were assisted at 11:41 AM

Moreover, LPA Martinez and LPA Pascua observed lunch in the facility dinning room. There were two kitchen staff working on this day, and caregivers were serving meals to residents. In addition, one kitchen staff 1 (K1) was assisting with serving meals to residents. It was also reported on June 6, 2022 there were two caregivers serving meals, and Kitchen staff (2) duties included, preparing meals, cooking meals, serving meals, washing dishes, cleaning kitchen. As a result, K2 was not able to complete some tasks. LPA Pascua was in the dinning room during lunch, and observed no caregivers from 12:04 PM to 12:12 PM. During this time, R2 did not have a drink. LPA Pascua assisted R2 by getting R2 a drink. As a result of LPA Martinez and LPA Pascua's observations, the facility does not have sufficient staff to meet the needs of the residents in care.

The Department finds the allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted with Kirk Goodin. A copy of this report, LIC 9099-D, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220323143616

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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE	FACILITY NUMBER: 342700886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/31/2022 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 (c) (4) Care of Persons with Dementia: Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety...	1 2 3 4 5 6 7	Administrator added 16 hours per day to The labor structure for caregiver. Follow Up with LPA Bi-weekly in regards to staffing numbers until 07/31/2022.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on observation the facility did not meet the needs of residents during an activity and lunch. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 07/31/2022 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	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 was not met as evidence by:	1 2 3 4 5 6 7	Staff training on care plans was conducted on 6/14-/6/15-6/16. conducting reassessments and writing new care plans. Assessments will be done by 07/31/2022. If facility staff needs additional time, Administrator shall contact LPA Martinez prior to 07/31/2022.
	8 9 10 11 12 13 14	Based on file review the facility did not meet R1's care needs. According to document "Resident Assistance Record" staff did not initial document stating care was provided to R1. It is unknown if care was being provided to R1. This posed a potential health & safety risk to R1.	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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC9099 (FAS) - (06/04)

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