342701159-1-25-2023-27-AS-KHOS-CNFRSF-20230126121640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701159
Report Date: 01/03/2023
Date Signed: 01/25/2023 03:53:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
11/22/2022 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221122143911

FACILITY NAME:	BEATRICE SENIOR CARE		FACILITY NUMBER:	342701159
ADMINISTRATOR:	MITITI, BIANCA		FACILITY TYPE:	740
ADDRESS:	8901 MELODIC CT		TELEPHONE:	(916) 270-3961
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Beatrice Clark		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care

INVESTIGATION FINDINGS:

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LPA Kesha Lewis conducted a complaint visit to this facility today to conclude a complaint for the allegations listed above. LPA met with Staff and Licensee and explained the purpose for today's visit.

Interviews with staff, interviews with outside care takers and documentation were reviewed that included chart notes and medical files. According to medical file reviews, chart note reviews and physician order reports, as well as staff interviews, Resident 1 (R1) sustained a unhealing wound while in care. Based on interviews with 1 staff members and one outside caretaker, R1 did sustain a pressure injury while in care of the facility. During review of medical files. LPA did discover R1 had sustained an unhealing wound. Therefore, the allegation: Resident sustained pressure injury while in care is Substantiated.

Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview held, a copy of report will be emailed as LPA'S printer is not working at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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-20221122143911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BEATRICE SENIOR CARE	FACILITY NUMBER: 342701159
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/27/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will develpo a plan on how to avoid residents sustainings wounds in the feature and sumbit to LPA Lewis via email by POC date.
	8 9 10 11 12 13 14	Based on LPA review of medical documentation and interviews with licensee and staff. R1 did not have any wounds when they came to the facility in June but by September the wound appeared. This poses a potential health, safety and personal rights risk of 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: Kesha Lewis	TELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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