342701230-10-24-2023-27-AS-KHOS-CX5R42-20231031124048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701230
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:46:20 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
09/15/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230915165919

FACILITY NAME:	SACRAMENTO SENIOR LIVING		FACILITY NUMBER:	342701230
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	6825 BENDER CT		TELEPHONE:	(510) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	6	CENSUS: 4	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Eliesa Qiolele		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff do not ensure that resident is admistered their medication(s) according to physician's instructions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with facility administrator Salote Lewis over the phone and explained the purpose of the visit.

This investigation consisted of interviews with facility administrator Salote Lewis, two staff members (S1-S2), and four residents (R1-R4), review of resident records, and observation. LPA Moleski reviewed medication administration records (MARs), centrally stored medication records, and medication labels for R1.

During a visit on September 21, 2023, LPA Moleski observed that a nighttime dose of antibiotic medication was not given to R1 on the evening of September 1, 2023, according to R1’s MARs. All other nighttime medications were administered on that date, according to the MARs.

[continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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 6

Control Number 27-AS-20230915165919

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
	VISIT DATE: 10/24/2023

NARRATIVE

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During that same visit, LPA Moleski observed signatures missing for nighttime doses of three medications listed for the evening of September 20, 2023, and for daytime doses of two medications for the morning of September 20, 2023.

During a visit on October 5, 2023, LPA Moleski observed four of R1’s medication bottles empty. S1 said staff had called to order refills but the pharmacies were running late. One of these medications, a 30-tablet bottle of an antibiotic, was started on September 2, 2023, according to R1’s centrally stored medication records. R1 was to take one tablet daily. According to R1’s MARs, R1 was given a dose of this medication each day from September 2, 2023 through October 3, 2023. Based on the start date recorded in R1’s centrally stored medication records, and based on the doses recorded in R1’s MARs, this medication should have run out on September 31, 2023, not on October 3, 2023.

During the same visit on October 5, 2023, LPA Moleski observed in R1’s centrally stored medication records that R1 started a 30-capsule bottle of medication on September 2, 2023. This medication was not listed on R1’s MARs for the month of September. LPA Moleski reviewed hospital discharge orders for R1 from a hospital visit dated August 21, 2023 to September 1, 2023 which discontinued the medication. On R1’s MARs for October 2023, R1 was given daily doses of the medication from October 1 to October 5, according to the MARs. During the same visit on October 5, 2023, LPA Moleski interviewed a staff member (S1). S1 said R1 was not given doses of the medication from October 1, 2023 through October 3, 2023, and admitted to falsely marking the MARs as if medication had been given, though none was. S1 said there was no new start order for the medication. LPA Moleski interviewed a second staff member (S2). S2 said R1 had been given doses of the discontinued medication on October 4, 2023 and October 5, 2023. During the same visit on October 5, 2023, LPA Moleski observed that only two capsules of the medication remained of the 30-capsule bottle. Based on doses signed off in R1’s MARs, a minimum of 25 capsules should have remained as of October 5, 2023. S1 said S1 flushed an unknown quantity of capsules at an unspecified date. S1 said there were no witnesses to this act. R1’s medication destruction records were blank as of October 5, 2023.

[continued on 9099-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230915165919

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
	VISIT DATE: 10/24/2023

NARRATIVE

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The department has determined the following as it relates to the allegation that staff do not ensure that resident is administered their medication(s) according to physician's instructions:

Based on interviews, record review, and observation, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87465(a)(4). Due to being a repeat violation, a civil penalty in the amount of $250 was assessed. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with staff member Eliesa Qiolele.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
09/15/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230915165919

FACILITY NAME:	SACRAMENTO SENIOR LIVING		FACILITY NUMBER:	342701230
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	6825 BENDER CT		TELEPHONE:	(510) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	6	CENSUS: 4	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Salote Lewis		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff are discriminating against resident.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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 6

Control Number 27-AS-20230915165919

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
	VISIT DATE: 10/24/2023

NARRATIVE

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The department has determined the following as it relates to the allegation that staff are discriminating against resident:

Based on interviews, the above allegation is UNFOUNDED. A finding that the complaint allegation is unfounded means the allegation is false, could not have happened or is without a reasonable basis.

An exit interview was held with Lewis and a copy of this report was left with staff member Eliesa Qiolele.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 27-AS-20230915165919

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/25/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	"The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct a staff training regarding medication administration. Licensee shall send LPA Moleski a sign-in sheet for this training and send a copy to LPA Moleski. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on observation, record review, and interviews, R1 was not given medication in accordance with doctor's orders, which poses an immediate health and safety risk.	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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

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