342701159-4-18-2023-27-AS-LKIG-CRBSCR-20230428134556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701159
Report Date: 04/18/2023
Date Signed: 04/18/2023 01:30:03 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, 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
03/07/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20230307080147

FACILITY NAME:	BEATRICE SENIOR CARE		FACILITY NUMBER:	342701159
ADMINISTRATOR:	CLARK, TIMOTHY		FACILITY TYPE:	740
ADDRESS:	8901 MELODIC CT		TELEPHONE:	(916) 270-3961
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 4	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Beatrice Clark		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility has insufficient staffing to meet residents' needs

INVESTIGATION FINDINGS:

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On 4-18-23 at 9:50am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the complaint allegation noted above. LPA was greeted by caregiver on duty. Administrator was not present initially and arrived at approximately 11:15am. During this investigation, LPA interviewed 6 residents and 2 staff members. LPA also reviewed facility file documentation including physician’s reports, staffing schedule, and facility’s plan of operation. Additionally, LPA conducted facility observations on 3-23-23 and 4-18-23. Based on record reviews and interviews, it was revealed that 4 of 6 residents required care and supervision for incontinence needs, 1 of 6 residents required a 2-person assist, and 1 of 6 residents required care and supervision related to dementia care on 3-23-23.
Based on records reviewed, it was revealed that facility schedule lists 2 staff on duty between 6am and 6pm and 1 staff on duty during the night shift hours of 6pm to 6am. Based on facility observation, it was revealed that 1 staff member was on duty for 6 residents in care on 3-23-23. Caregiver on duty was assisting one resident with toileting needs resulting in multiple residents with care needs not supervised by the additional scheduled caregiver due to not being present in the facility. {Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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 27-AS-20230307080147

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BEATRICE SENIOR CARE	FACILITY NUMBER: 342701159
	VISIT DATE: 04/18/2023

NARRATIVE

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Interviews conducted revealed facility required additional caregiver oversight on multiple occasions for purposes of meeting care and supervision needs, and to be consistent with established facility staffing schedule. A review of facility’s plan of operation revealed a statement in the plan of operation which states: "Staff is available 24 hour a day to assist with resident needs”

As a result, based on interviews, record reviews, and observations, it is determined that licensee did not adhere to established facility staffing schedule, and ensure appropriate staffing levels necessary to monitor for the physical and psychosocial well-being of residents care needs as noted through record reviews. Therefore, this allegation is SUBSTANTIATED.

Citation is issued under Title 22, Division 6 An exit interview was conducted with Beatrice Clark and a copy of this report was provided to Beatrice. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230307080147

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BEATRICE SENIOR CARE	FACILITY NUMBER: 342701159
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2023 Section Cited CCR 87413(a)(1)	1 2 3 4 5 6 7	87413(a)(1) Personnel-Operations. (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will read regulation 1569.312(e) and submit a signed declaration of understanding to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review, interviews, and observation, licensee did not ensure appropriate staff coverage consistent with facility staffing schedule for purposes of monitoring the activities of residents for their general health, safety, and well-being. This posed a potential health and safety risk to residents in care.	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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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