342701248-12-1-2023-27-AS-CACL-CYAT76-20231207132812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:38:27 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
11/27/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20231127140349

FACILITY NAME:	SACRAMENTO SENIOR LIVING II		FACILITY NUMBER:	342701248
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	34 LOMA MAR CT		TELEPHONE:	(530) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2023
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Misivono Qadroka		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Medications:
1) Staff mishandled a resident's medication while in care.
2) Staff have inadequate record keeping for a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Sacramento Senior Living II RCFE on 12/1/23 at 1:00pm to inform the licensee of complaint allegations mentioned above and to deliver the findings. LPA met with Staff Misivono Qadroka and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because LPA reviewed resident records and medication administration records and observed several instances for all residents where the medication administration was not documented according the the facility program and title 22 regulations. There was no documentation for any residents medication administration on today's date. Additionally LPA observed that there were gaps in the medication administration due to alleged waiting for pharmacy refills but LPA determined the refill request was made after the recommended date of the refill and resident was not administered medications per physician's orders.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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 3

Control Number 27-AS-20231127140349

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: SACRAMENTO SENIOR LIVING II	FACILITY NUMBER: 342701248
	VISIT DATE: 12/01/2023

NARRATIVE

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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegations of Medications is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20231127140349

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: SACRAMENTO SENIOR LIVING II	FACILITY NUMBER: 342701248
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/02/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidence by LPA review of all resident MARs and observation of incomplete documentation of	1 2 3 4 5 6 7	facility will provide training to all staff member who administer medications and the appropriate steps in documenting medication once it is given to the residents.
	8 9 10 11 12 13 14	medication administration with poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 12/02/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. the requirement was not met as evidenced by LPA observed there were several days resident did not receive medications due the waiting on refill and LPA observed in documentation the refill request was made once med	1 2 3 4 5 6 7	facility will provide a written plan of correction indicating the changes and steps the facility will make to ensure resident medications are refilled and available for residents as prescribed by the physician.
	8 9 10 11 12 13 14	the medication refill order was not made until resident was out of medications which poses an immediate health safety and personal rights risk to residents in care	8 9 10 11 12 13 14

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

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