342700902-5-16-2023-59-AS-KHOS-CSCNSE-20230531104300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 05/16/2023
Date Signed: 05/16/2023 09:46:42 AM

Unfounded

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
05/04/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230504164039

FACILITY NAME:	FOLSOM COUNTRYHOUSE		FACILITY NUMBER:	342700902
ADMINISTRATOR:	THACH DUONG		FACILITY TYPE:	740
ADDRESS:	2005 IRON POINT RD		TELEPHONE:	(916) 836-8022
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	60	CENSUS: 40	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator: Danielle Peck		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident pushed resident causing hip fracture.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/16/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 05/04/2023. LPA met with Executive Director (ED), Danielle Peck, and explained the purpose of the visit.

During the course of investigation, the Department interviewed facility staff, and obtained pertinent documents relevant to the complaint investigation such as, residents’ (R1 and R2) physician’s report, assessments, medical records, staff roster, incident reports, SOC 341, video footage for review.

Continue on page LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 2

Control Number 59-AS-20230504164039

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: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
	VISIT DATE: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 04/28/2023, the facility submitted two incident reports and SOC 341 to the Department for review. According to the first incident report on 04/28/2023 at approximately 4 PM, after the care staff was done assisting another resident near the living room, R1 was on the floor sitting down next to the chairs. R1 denied pain and was able to get up with minimal assistance. R1 was unable to recall how R1 fell. R1’s daughter arrived at the community and R1 complained of pain on right hip. EMS was activated to assess R1 and transported R1 to the hospital for evaluation. Second incident report indicated on 4/28/2023 at approximately 6:30 PM, while community was reviewing the video footage involving R1. R2 was involved and was seen pushing R1 that was trying to grab R2’s cane that has resulted to a fall incident. Fall incident resulted in R1’s hip fracture.

The Department requested and received R1 and R2’s physician’s report and assessments for review. According to R1 and R2’s physician’s report, residents are diagnosed with Dementia. R1 and R2’s assessments indicated, both residents needs some supervision. The Department reviewed the video footage of the incident that was submitted by the facility. Video footage shows R1 and R2 in the common area with a care staff. Care staff was seen leaving R1 and R2 to the next room for less than 30 seconds. While staff was at a short distance away from residents, R2 pushed R1 which resulted in a fall. Care staff returned and witnessed R1 on the floor and used a walkie talkie to report the fall. The facility has done their due diligence by activating EMS to access R1, transported R1 to the hospital for further evaluation in a timely manner, notified R1 and R2’s responsible parties, and R1’s PCP.

ED submitted facility’s plan to prevent this type of incident from occurring again. Folsom CountryHouse staff will continue to provide positive resident engagement by encouraging residents to participate in scheduled activities. Redirect residents who appear to be agitated to different areas of interest. Appropriate staffing to observe interactions with residents who have had any previous incidents to help prevent issues. Staff to continue to receive training for dementia behaviors and redirection.

Based on information above, department concluded the allegation is UNFOUNDED, A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

No citations were issued today. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2