342701028-4-13-2022-25-AS-TORZ-CE2P3K-20220502105737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701028
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:50:31 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20211118152214

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:	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Tatleen Lewis		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was not accorded dignity

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced and conducted a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary pre screening, and wore a surgical mask while at facility.

The department investigated the allegation "Resident was not accorded dignity". The department interviewed staff and reviewed resident records.
LPAs interviewed caregivers. One caregiver admitted there was one time a resident was changed with the door open. The resident was not afforded dignity and respect due to being changed with the door open and not given any privacy. Caregiver stated it has not happened since.

Based on the above, the allegation is substantiated. The following deficiencies were cited on 909-D, per Title 22 Regulations, Division 6. Appeal rights left with facility representative.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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 25-AS-20211118152214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MKS QUALITY CARE LLC	FACILITY NUMBER: 342701028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/14/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	By 04/14/2022, Licensee shall at mimimum schedule resident personal rights' training for all staff and submit the training schedule to Licensing.
	8 9 10 11 12 13 14	This was not met as evidenced by: a caregiver admitted she didn't close the door one time when a resident had to be changed. This poses an immedate risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20211118152214

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: 8	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Tatleen Lewis		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Resident sustained multiple injuries while in care.
2. Licensee did not ensure that resident was regularly observed for changes in functioning.
3. Facility did not properly screen visitors according to COVID-19 protocols

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced and conducted a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.
The department investigated the allegation "1. Resident sustained multiple injuries while in care; and 2. Licensee did not ensure that resident was regularly observed for changes in functioning". The department interviewed staff and reviewed resident records.

1. Per an interview with the doctor, a vertebral fracture was found, and the doctor could not determine the exact cause and the exact time frame the injury occurred. The doctor stated it could have happened roughly 30 days prior to the fracture being found until the day it was found due to the condition of the resident’s health and that it could occur with or without major trauma. The facility file shows the resident had a fall three days prior to being sent to the hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20211118152214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MKS QUALITY CARE LLC	FACILITY NUMBER: 342701028
	VISIT DATE: 04/13/2022

NARRATIVE

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The fracture was found by an x-ray at the hospital and the doctor interviewed stated the exact cause and time of the injury could not be determined due to the health condition of the resident. The resident was seen the day after the fall during a routine visit by an RN from a home health care agency and the nurse did not observe any conditions that warranted the resident be sent to the hospital.

2. Records show the resident had multiple visits for physical and occupational therapy, and home health care agency nurses over the course of 13 days. Staff reported two days prior to hospitalization that resident was lethargic and less active but was not severe enough to seek medical attention. When the condition did not improve, and the resident appeared flushed the resident was sent to the emergency room.

Based on all the above the department could not prove or disprove the allegations and the allegations are unsubstantiated.

LPAs Hiratsuka and Muscan, investigated the following allegation: 3 Facility did not properly screen visitors according to COVID-19 protocols.

Interviews with caregivers stated they screen all visitors and ensure the visitors are wearing masks, taking temperatures, and signing all visitors in. Complainant stated the staff didn't always check the visitor in, but did make sure the visitor was wearing mask. During today's visit a visitor did arrive and was screened. Based on the above, the allegation cannot be proved or disproved. Allegation is unsubstantiated.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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