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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002857
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:07:19 PM


Document Has Been Signed on 09/10/2024 04:07 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ROBERT CREEK VILLAFACILITY NUMBER:
345002857
ADMINISTRATOR:KING, MARICARFACILITY TYPE:
740
ADDRESS:8134 ROBERT CREEK COURTTELEPHONE:
(916) 728-6465
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Maricar King, Administrator TIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report submitted to the Department on 8/30/24. LPA met with Karmen Szilvassy, caregiver, who contacted the Administrator. LPA spoke with Maricar King, Administrator, by phone, who stated she was unable attend the inspection. LPA stated the purpose of today's inspection.

The incident report notes that on 8/28/24, resident (R1) was sitting in their wheelchair outside on the backyard patio, and at approximately 11:00 am, a visitor observed that (R1) had fallen out of their wheelchair in front of the facility. (R1) was assessed, provided first aid, and immediately sent to the hospital for further medical attention. LPA reviewed paperwork for (R1). Physician's report notes resident (R1) has cognitive impairment, is confused, and cannot leave the facility unassisted; however, it's not noted to have elopement tendencies.

Caregiver (S1), who was present during the incident, stated to LPA today that she gave (R1) and resident (R2) glasses of water at the dining table before taking a short bathroom break. (S1) stated within (5) minutes, a visitor was knocking at the door to let her know (R1) had fallen from their wheelchair and into the street. (S1) stated she is not sure if (R1) exited through the front door or through the door leading to the backyard patio, to get to the front of the facility. LPA observed that the side outdoor gate is able to be pushed opened and does not have a locking mechanism. (R1) stated to LPA that they exited the facility from the common area to the outside patio and then through the side gate to reach the front driveway area. The Administrator stated that (R1) was outside on the patio and pushed the gate open to the front driveway are, commenting that (R1) tried to ambulate to the front yard before. (S1) stated (R1) will regularly go outside, after lunch, for about (10) minutes, is always supervised and has not tried to leave the facility previously. LPA observed during today's inspection, there is currently not a functioning alarm on the front door and learned the alarm on the patio door was turned off during the incident, as it regularly is during the daytime hours, including during today's inspection. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency is issued on the 809-D page. Exit interview with caregiver as authorized by Administrator. Copy of report and appeal rights provided by email to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/10/2024 04:07 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ROBERT CREEK VILLA
FACILITY NUMBER: 345002857

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
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Licensee/Administrator agrees to install a functioning alarm feature on the front exit door and to ensure the alert feature is always turned "on" on the sliding door leading to the patio. Also, agrees to ensure that there is a working alert feature on the glass sliding door in rooms #3 and #4. Alert feature for room #5 is currently working.
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Based on observation and interviews conducted on 9/10/24, the Licensee did not ensure there was a functioning alert feature on the front exit door and on the side patio door leading to the backyard on 8/28/24, which posed an immediate health and safety risk to residents in care.
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Documentation that an alarm has been installed on the front door to be submitted to the Department by 9/12/24.

LPA may return in the near future to confirm that a door alarm has been installed.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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