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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700950
Report Date: 07/19/2023
Date Signed: 07/19/2023 11:26:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/30/2023 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230630152336
FACILITY NAME:DELL ROAD HOMEFACILITY NUMBER:
342700950
ADMINISTRATOR:MAGEE, ANDREWFACILITY TYPE:
740
ADDRESS:3840 DELL ROADTELEPHONE:
(916) 333-3103
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:0CENSUS: 3DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Persida PopTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not ensure resident medication was provided as prescribed.
INVESTIGATION FINDINGS:
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 On 7/19/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Administrator to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted interviews.
LPA finds that the allegations cited above are substantiated.
Records and interviews showed the R1 was a resident receiving Hospice care.
R1’s hospice care plan and records showed that R1 was to receive several medications for pain management and agitation. Records and interviews found that medication was not administered as prescribed, at times, due to disagreeement with the hospice plan and family wishes.
R1 was transferred from the home to a facility that would follow with the hospice plan for medication management of R1's symptoms.
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.
Report reviewed with . Copy of this report and appeal rights provided.
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: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 59-AS-20230630152336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELL ROAD HOME
FACILITY NUMBER: 342700950
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2023
Section Cited
CCR
87468.1(b)(8)
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Personal Rights of Residents in All Facilities.
(b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. A licensee or facility staff may not take any of the following actions,...(8) Deny or restrict medical
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Resident has moved from the facility. Licensee will submit a statement of understanding of the conditions and duties of accepting and retaining Hospice residents to include adherence to Hospice Plan and resident ( responsible party) wishes.
POC due by 7/26/23.
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or nonmedical care that is appropriate to a resident’s ... needs, or provide medical or nonmedical care to the resident... unduly ... causes avoidable discomfort. This requirement was not met based on records and statements. This posed immediate undo discomfort 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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
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