342701028-7-25-2023-25-AS-LMUZ-CU3UL5-20230725154010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701028
Report Date: 07/25/2023
Date Signed: 07/25/2023 01:29:27 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
10/24/2022 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221024135603

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:	12:38 PM
MET WITH:	Maria Cucicea		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained injuries while in care.
Resident is not given privacy.
Resident suffered falls while in care.

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 two Administrator, current and previous staff, and hospice agency. LPA reviewed R1’s file including R1’s physicians report, care plan, and resident notes.

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 injuries due to a fall while in care, this was not the result of insufficient staffing. Based on interviews with current and former staff, R1 had a history of wandering around their room at night and attempting to toilet themselves.
LPA interviewed current and former staff which stated that when R1 would receive phone calls on the facility phone, they would hand them the phone and then provide them privacy. Sometimes the staff would

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-20221024135603

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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have the phone on speaker phone but would not stay to listen to the conversation. Once R1 completed their phone call, they would signal to staff to get the phone in the entryway to their apartment, or bring it out to staff.

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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