342701228-3-28-2023-27-AS-LKIG-CQU24U-20230412170429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701228
Report Date: 03/24/2023
Date Signed: 03/28/2023 10:25:00 AM

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
02/03/2023 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230203170904

FACILITY NAME:	COMFORT LIVING ELDER CARE 3		FACILITY NUMBER:	342701228
ADMINISTRATOR:	SOUMAHORO, MARIAM G		FACILITY TYPE:	740
ADDRESS:	8765 INISHEER WAY		TELEPHONE:	(510) 409-7096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 4	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Teresita Agnanos		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident developed pressure injuries due to staff not turning resident as needed.

INVESTIGATION FINDINGS:

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Based on a review of the hospice notes dated in January of 2023 , and interviews wiht the staff. The allegation is substantiated.

As a result of this investigation, the Department finds the allegation 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.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in an unstageable wound. Failure to correct the deficiency may result in additional civil penalties.

At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 15610.67 Appeal rights were provided.

Exit interview conducted and a copy of the report and appeal rights were given.

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: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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-20230203170904

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: COMFORT LIVING ELDER CARE 3	FACILITY NUMBER: 342701228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 (f)(1)Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met based on	1 2 3 4 5 6 7	Licensee shall review the regulation to ensure residents recieve Basic services care and supervision as defined in Section 87101(c), and submit a letter to the LPA stating they understand the regulation.
	8 9 10 11 12 13 14	The department's findings. The facility failed to prevent resident from developing pressure injuries due to staff not turning resident as needed. This posed an immediate health and safety risk to R1.	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: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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