345002840-1-30-2025-25-AS-SCAA-CM4247-20221213160327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002840
Report Date: 12/13/2022
Date Signed: 01/30/2025 10:34:41 AM

Document Has Been Signed on 01/30/2025 10:34 AM - 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:	ELIZABETH CARE HOMES IV		FACILITY NUMBER:	345002840
ADMINISTRATOR:	EKANEM, UWEM IME		FACILITY TYPE:	740
ADDRESS:	7131 MATHIS COURT		TELEPHONE:	(650) 248-1108
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/13/2022
TYPE OF VISIT:	Case Management - Deficiencies	ANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Franca Offor, House Manager		TIME COMPLETED:	04:05 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 Analysts (LPA) Sabrina Calzada and Melissa Parks arrived unannounced to conduct a follow up case management inspection related to resident (R1) who resided at the facility from approximately 3/3/2021 to 11/4/2022. Previously on 10/3/22, LPA Calzada conducted a case management inspection, while at the facility for a required annual inspection, and spoke with R1’s responsible person and home health care nurse who was providing wound care to resident (R1). LPA's met with Theresa Okwara and Muheebat Adelekan, caregivers and explained purpose of inspection. LPA met with Franca Offor, House Manager, who arrived at 2:45 pm. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: KN95 or surgical mask. LPA reviewed home health care records for resident (R1) for the period 11/8/2021- 10/14/2022. Resident was discharged on 3/7/22 due to reaching maximum rehab potential and was referred again on 3/8/22 and admitted for weekly physical therapy through 4/28/22 to increase strength, balance and transfer. Home health notes from 5/3/22 indicate it is the initial visit for two, stage 2 wounds that developed on 4/25/22 that were located on the upper right and left buttocks, that were caused from prolonged sitting. Care staff was instructed to do on/off loading using resident's cushion. There were no Home Health records received for the period from 5/10/22- 9/6/22; however, records do show that resident received a first visit for new certification period on 9/7/22, which notes resident had the onset of a wound on 7/28/22. Home health notes show on 9/20/22, nurse observed (2) new stage 2 pressure sores on inner left and right knees and indicate an onset date of 9/19/22. The next home health visit on 9/27/22 document the sore on the Left knee that was previously a stage 2 to now present as DTI (Deep Tissue Injury)- caregiver to change on skilled nursing off days, the right knee stage 2 is now presenting as Unstageable, the wound on the coccyx remains a stage 2, and notes a new pressure Stage III wound on left lower buttocks. The next home health visit on 9/30/22 documents the sores on both knees and coccyx to remain as stage 2, and the wound on lower left buttocks to remain a stage 3; continued on 809C(1) page..

Maribeth Senty	TELEPHONE: (916) 263-4813
Sabrina Calzada	TELEPHONE: (510) 829-2133
	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: ELIZABETH CARE HOMES IV	FACILITY NUMBER: 345002840
	VISIT DATE: 12/13/2022

NARRATIVE

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809C(1) Home health care notes consistently note that caregivers were instructed and they verbalized their understanding of care instructions to reposition client every 2 hours.

Home health notes from 10/3/22 document that the wound on the right knee that was previously a stage 2 is now DTI, the left knee was previously Stage 2 and is now UNSTAGEABLE; the wound on the coccyx remains a stage 2, and the wound on lower left buttocks has worsened from a stage 3 and isnow presenting as UNSTAGEABLE. Notes also document that wound care increased from 2x/week to 3x/week, effective 10/5/22 due to facility being unable to provide wound care, Caregivers were instructed on pressure relieving devices and to limit sitting to 1-2 hours/day and to ensure adequate nutrition and hydration.

No change in wound appearance on 10/5/22,10/7/22, 10/12/22, and home health document wound care on the buttocks was healing when observed on 10/14/22.

Home health Nurse stated to LPA Calzada on 10/3/22 that resident (R1) had a Stage 2 that has turned into a Stage 3 from a week ago. Nurse also stated that a month ago, on 9/3/22, the "wound had almost closed" but last week when she came out to provide wound care, the wound had become a Stage 2. The nurse stated that staff is supposed to be following the wound care orders of "not letting her sit" for more than 1 hour and that after each H/H visit, she calls the family to discuss the visit and also instructs the caregivers on specific instructions.

LIC602 dated 1/21/2021 indicates resident has a history of skin breakdown, uses Neosporin on the coccyx, is incontinent Hospital discharge paperwork shows resident was treated for a pressure ulcer on the right buttock on/around 6/2/2021. Resident's pre-appraisal and care plan dated 3/9/2021 does not indicate that resident has any skin breakdown or pressure sores. Also, the care plan dated 3/9/2021 was developed under the prior ownership that was in effect until 10/13/2021.

Resident’s care plan was not updated in March 2022, 12 months from the initial care plan, or in June 2021 following resident’s discharge from the hospital with a pressure sore. Additionally, there is not an updated care plan on file to reflect the onset of ulcer wounds on 4/25/22, 7/28/22, 9/19/22, or the worsening of wounds on 9/27/22 and 10/3/22.

cont on 809C(2)....

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: ELIZABETH CARE HOMES IV	FACILITY NUMBER: 345002840
	VISIT DATE: 12/13/2022

NARRATIVE

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809C(2).. Based on medical home health documentation reviewed, the Licensee did not ensure that staff followed home health wound care instructions, which caused additional pressure sores to develop on 4/25/22, 7/28/22, 9/19/22, and worsen on 9/27/22, 10/3/22 and again on 11/4/22. Resident was sent to the Emergency Room on 11/4/22 due to the severity of the wounds and was admitted to the hospital with a diagnosis of sepsis.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (4)deficiencies are issued on the 809D pages.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.

Exit interview. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2022 04:03 PM - It Cannot Be Edited

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: ELIZABETH CARE HOMES IV	FACILITY NUMBER: 345002840
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(a)(3)

87465 Incidental Medical and Dental Care- (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requiremet is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/15/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator agree to conduct staff training regarding following home health orders including wound care, repositioning, and skin integrity.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Maribeth Senty	TELEPHONE: (916) 263-4813
Sabrina Calzada	TELEPHONE: (510) 829-2133
	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 12/13/2022 04:03 PM - It Cannot Be Edited

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: ELIZABETH CARE HOMES IV	FACILITY NUMBER: 345002840
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87467(a)(3)

87467(a)(3) - Resident Participation in Decisionmaking. (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/30/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator agree to conduct a file audit for each resident and ensures that all residents have updated care plans. Facility will fax updated forms to LPA.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Maribeth Senty	TELEPHONE: (916) 263-4813
Sabrina Calzada	TELEPHONE: (510) 829-2133
	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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