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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701218
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:13:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
05/20/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240520094411
FACILITY NAME:ROYAL GROVE CARE HOMEFACILITY NUMBER:
342701218
ADMINISTRATOR:ROSA ELMA QUIAMBAOFACILITY TYPE:
740
ADDRESS:9559 LAZY SADDLE WAYTELEPHONE:
(916) 829-4117
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Jyd Leong, Caregiver TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care
Facility did not seek timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to deliver the findings of the complaint investigation on 10/25/24 at 8:30am. LPA met with Jyd Leong, Caregiver and stated the purpose of the visit.

Regarding allegation, “Resident developed multiple pressure injuries while in care” The Departments investigation revealed that the Admission Agreement dated 12/23/23, indicated R1 needed assistance with activities of daily living (ADL’s), and needed a 2-person assist for transfers. Per Medical Records, a skin assessment determined R1 to have multiple wounds on their back with maggots and wounds on left and right leg, buttock, and abdomen. Staff reported during interviews that R1 would refuse rotation and scream at them when they tried to lift to provide care. Staff stated that they couldn’t care for R1 anymore due to the weight of R1. Staff were shown a photo of R1s entire back. They all denied seeing R1’s back in the state that was in the photo with maggots.
Based on medical records and interviews the allegation is deemed - Substantiated.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 5
Control Number 27-AS-20240520094411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROYAL GROVE CARE HOME
FACILITY NUMBER: 342701218
VISIT DATE: 10/25/2024
NARRATIVE
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Regarding allegation, “Facility did not seek timely medical attention”, On 5/14/24, staff noted R1 needed medical attention, but R1 refused. Staff felt 911 should have been called anyway. On 5/16/24, 911 was contacted and R1 declined when they arrived. It wasn’t until 5/17/24 where R1 was taken to the hospital for shortness of breath. Based on a review of documentation, and interviews the preponderance of evidence standards has been met.

Due to this information from interviews and medical records review, Community Care Licensing (CCL) finds this allegation(s) to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

You are hereby notified that a civil penalty in the amount of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49 is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining pressure injuries (serious bodily injury) while in care of the facility.

Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Caregiver was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
Exit interview held with Administrator. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20240520094411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROYAL GROVE CARE HOME
FACILITY NUMBER: 342701218
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/26/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Condition
Persons who require health services for ...specified below shall not be admitted or retained ...:(1) Stage 3 and 4 pressure injuries.
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Administrator shall submit a statement of understanding of this requirement to not allow a resident to be retained without an exception being granted by CCL and that Title 22 regulations will be adhered to at all times.

Please fax by POC due date.
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This requirement is not met as evidenced by: Based on a review of documentation, medical records, and interviews the facility retained R1 with multiple pressure injuries without a hospice referral from physician nor did they request an exception from the Department. This poses an immediate health and safety risk to residents in care.
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You are hereby issued an Immediate Civil Penalty in the amount of $500.00.
An additional civil penalty determination is pending. Failure to comply will result in additional citations and civil penalties.


Under Appeal
Type A
10/26/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care Services The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Administrator shall submit a letter stating that the Title 22 regulations will be adhered to at all times.

Please fax by POC due date.
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This requirement is not met as evidenced by: Based on a review of documentation, and interviews the facility did not seek medical attention in a timely manner for R1. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
05/20/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240520094411

FACILITY NAME:ROYAL GROVE CARE HOMEFACILITY NUMBER:
342701218
ADMINISTRATOR:ROSA ELMA QUIAMBAOFACILITY TYPE:
740
ADDRESS:9559 LAZY SADDLE WAYTELEPHONE:
(916) 829-4117
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Jyd Leong, Caregiver TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Suspicious death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to deliver the findings of the complaint investigation on 10/25/24 at 8:30am. LPA met with Jyd Leong, Caregiver and stated the purpose of the visit.

Regarding allegation,” Suspicious death”, the Departments investigation revealed the Admission Agreement dated 12/23/23 noted the family was responsible for R1 and the section was initialed that mentioned “residents rights to make decision concerning medical care including the right to accept or refuse treatment and the right under state law to formulate an advance health care directive”.

On 5/14/24, staff noted R1 needed medical attention but R1 refused. On 5/16/24, 911 was called and R1 refused to be taken to hospital. On 5/17/24, 911 was called and R1 was taken to hospital for shortness of breath.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240520094411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROYAL GROVE CARE HOME
FACILITY NUMBER: 342701218
VISIT DATE: 10/25/2024
NARRATIVE
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Medical Records revealed that R1 had severe respiratory distress and impending respiratory failure.

Medical Records also indicated that R1 was managing health care by using a messaging system to request care.

CCL observed that R1’s death certificate indicates on 5/17/24, the cause was septic shock and pneumonia.

The interval between onset and death for septic shock was 14 hours and pneumonia were days.

Based on records review the allegation is deemed – Unsubstantiated.

A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, copy of report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5