345002811-9-29-2022-25-AS-SCAA-CJQVTJ-20220929164312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002811
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:43:23 PM

Document Has Been Signed on 09/29/2022 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	CAREHAVEN VALENCIA		FACILITY NUMBER:	345002811
ADMINISTRATOR:	KIM, DAVID		FACILITY TYPE:	740
ADDRESS:	7545 ORANGE DRIVE		TELEPHONE:	(916) 928-7017
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 4	DATE:	09/29/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Jina KIm, Co-Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a case management inspection to follow up on an incident report received following an incident occurring on 9/1/22. LPA met with Julie Smith and Miranda Mangahas, caregivers and explained purpose of inspection. LPA spoke with David Kim and Jina Kim, Administrators, by phone and explained the purpose of the visit. Prior to conducting today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA met with Jina Kim, Co-Administrator, in person, at the facility around 2:45 pm and discussed the incident in more detail when resident (R1) fell. Both Administrators stated that R1 fell after using the private bathroom during the night. and fractured multiple ribs and was sent to the hospital. Resident was admitted and returned to the facility with home health services starting on 9/5/22, and has been walking using a walker and also has a wheelchair for mobility. R1 was placed on hospice on 9/22/22 due to a diagnosis of Dementia and weight loss before moving to the facility. LPA reviewed R1's file. The pre-appraisal notes resident is able to walk short distances with a walker and is a fall risk but does not need night supervision. Hospital discharge papers indicate R1 is a high fall risk and tested positive for a UTI when admitted on 9/1/22. Discharge papers also show that based on camera footage, R1 fell on 9/1/22 due to losing her legs getting crossed, bumped her head on the soft part of the bed and hit her left chest against the hard floor. Due to R1's diagnosis of Dementia, R2 will call staff for assistance for R1, and R2 called for help when he saw R1 fall. The facility has staff who are on-call during the night since residents typically sleep through the night. R1 was recently prescribed a sleeping medication on 9/20/22 and has not awoken to use the bathroom since. LPA discussed camera being used in R1's shared room with R2. Administrator stated that R2 and his family gave consent for the camera and showed LPA several text messages. Cont on 809C..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CAREHAVEN VALENCIA	FACILITY NUMBER: 345002811
	VISIT DATE: 09/29/2022

NARRATIVE

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809C(1).. An Technical Advisory note will be issued today. LPA discussed how written consent needs to be obtained from both R1/R2 and family before continuing to use.

LPA reviewed hospice care binder for R1 and confirmed resident began services on 9/22/22. and hospice nurses have made several visits so far. LPA did not see an updated copy of the care plan for R1. Administrator called hospice company and requested a copy be provided to the facility today. Hospice company stated the physician needs to sign the care plan and they will fax it over tomorrow morning.

LPA was able to briefly speak to R1 or R2 and observed the room. R1 has a hospital bed next to the wall and close to the bathroom. Both R1 and R2 were happy to speak to LPA and appeared to be in good spirits.

Also discussed was R2's family wanting to place R2 also on hospice, if eligible. LPA provided information on how to request a hospice increase waiver. LPA referenced Regulations 87632 and 87633 to review and include in the hospice waiver request.

Exit interview. Copy of report provided to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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