342701028-7-25-2023-25-AS-LMUZ-CU3UK7-20230725153838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701028
Report Date: 07/25/2023
Date Signed: 07/25/2023 01:27:09 PM

Unsubstantiated

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
10/17/2022 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221017164805

FACILITY NAME:	MKS QUALITY CARE LLC		FACILITY NUMBER:	342701028
ADMINISTRATOR:	LEE, KEVIN		FACILITY TYPE:	740
ADDRESS:	317 NATOMA ST.		TELEPHONE:	(916) 831-7972
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	15	CENSUS: 7	DATE:	07/25/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maria Cucicea		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.
Staff did not allow resident to have family visitation.
Staff are making health decisions for residents without the consent of the resident's authorized person.

INVESTIGATION FINDINGS:

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LPA Parks arrived on Tuesday July 25, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Maria and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, current staff and previous staff. LPA attempted to interview Hospice employees but learned that none of the assigned hospice employees for R1 were currently employed. LPA reviewed R1’s file including R1’s physicians report, care plan, incident reports, assessments, and hospice visit notes. LPA reviewed facility staffing for the duration of R1’s time at the facility. The result of the investigation is as follows:

LPA reviewed staffing schedules and learned that the facility has a maximum capacity of 15 residents. The facility staffs 3 caregivers during the day shift and one staff for the overnight shift. At the time of R1’s fall, there were only 10 residents at the facility. LPA determined that while R1 did sustain a fracture while in care, this was not the result of insufficient staffing. R1 and their spouse (R2) both lived at the facility

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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 25-AS-20221017164805

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: MKS QUALITY CARE LLC	FACILITY NUMBER: 342701028
	VISIT DATE: 07/25/2023

NARRATIVE

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but in separate apartments. Staff would assist R1 with visiting R2 and upon request. LPA interviewed current and former staff who were at the facility when R2 was actively passing. Interviews revealed that they assisted R1 with visitation, and at no time was visitation denied.

Interview with R1’s hospice agency revealed that this decision was made by R1’s POA. R1’s POA changed hospice agencies during R1’s stay at the facility. Interview with staff stated that they are not involved with selecting a hospice agency.

Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

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