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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000947
Report Date: 01/29/2021
Date Signed: 01/29/2021 12:07:48 PM



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
09/16/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200916144305
FACILITY NAME:NORA'S HOME CARE #2FACILITY NUMBER:
347000947
ADMINISTRATOR:BERCI, ELEONORAFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVENUETELEPHONE:
(916) 536-0240
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:0CENSUS: 0DATE:
01/29/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nora Berci, Licensee and Kevin Lee, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident given wrong medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada contacted prior Licensee, Nora Berci, and Administrator, Kevin Lee, of new license, via tele-visit to deliver complaint findings to a complaint the department received on 9/16/2020. The facility had a change in ownership, and a new license was approved on 12/10/2020. Findings are being delivered via tele-visit due to current Covid-19 precautionary measures in place.

During the investigation, LPA interviewed Licensee, Administrator, House Manager, (2) staff, representative from an outside agency, and Ombudsman. LPA reviewed documentation including, but not limited to, resident's (R1's) Physician Report, Needs and Services Plan, Medication Administration Record (MAR), medication orders, Unusual Incident/Injury Reports (LIC624), hospital discharge paperwork, letter regarding change in ownership, and Designation of Facility Responsibility (LIC308).

The results of the investigation are as follows:

Complaint report received states that resident was given Glipizide 10mg, which is for diabetics, and was diagnosed as hypoglycemic after going to the emergency room and having her blood tested.
Interview with House Manager indicated that after resident went to the Emergency Room (ER) on 9/8/20, she received a phone call from the emergency room physician asking if resident was diabetic. House Manager confirmed that resident is not diabetic, she was not aware of any medication errors and "doesn't know how resident got low blood sugar". A staff member stated she took resident's blood sugar and it was low and emergency medical technicians also indicated that resident's blood sugar was low prior to taking resident to the ER. LIC624 notes that resident was sent out on 9/8/2020 @11:50 am, as resident was leaning to one side in a wheelchair and didn't look right, so 911 was called. Staff stated that resident possibly had low blood sugar due to eating less and skipping meals because resident's friend would bring resident food and snacks.
cont on 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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-20200916144305
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: NORA'S HOME CARE #2
FACILITY NUMBER: 347000947
VISIT DATE: 01/29/2021
NARRATIVE
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Per Physician's Report dated 1/25/2019, resident does not have a diagnosis of Diabetes. Further, medication orders for resident, R1, do not show an order for Glipizide 10mg, which is also not listed on the MAR for September, 2020. Medication orders for resident (R2) reveal that Glipzide 10 mg was prescribed to be taken twice daily, at 8:00 am and at 5:00 pm, before a meal and to hold if blood sugar is less than 90 or resident is not eating. Review of MAR for resident (R2) shows that Glipizide was administered as scheduled on 9/1/20- 9/7/20, per staff's initials; however days 9/8/2020- 9/18/2020 were not initialed by staff for the 8:00 am dosage when LPA was reviewing the document on 9/18/2020. LPA brought it to the attention of the House Manager who discussed it with staff member who then initialed those same days on the MAR during LPA's inspection. House Manager stated staff overlooked initialling the MAR on those days. A representative from another agency who interviewed resident(R1) indicated that resident stated that a staff member was confused about resident's (R1's) medications and gave resident another resident's medication, Glipizide.

Hospital Medical documentation from 9/8/2020 emergency room visit was not available for review. Resident did not return to the facility upon discharge but transferred to a skilled nursing facility for physical therapy.

Based on information obtained, LPA finds the allegation: "Resident given wrong medication" to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency was cited on 9099D, per Title 22 Regulations, Division 6, Chapter 8. Failure to correct the deficiency by the noted due date may result in a penalty being assessed.

Exit interview. Copy of report provided to Administrator.


SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20200916144305
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: NORA'S HOME CARE #2
FACILITY NUMBER: 347000947
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2021
Section Cited
CCR
87465(a)(5)
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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: (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Administrator agreed to conduct staff training on Medication Administration- specifically, staff will complete a training module individually on medication administration. Administrator agrees to submit documentation of staff training and topics covered to the CCLD by fax by 2/12/2021. Attn: LPA Calzada
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Based on interviews and records reviewed, resident (R1) was administered Glipizide 10 mg on 9/8/2020 which was not prescribed for resident, which posed an immediate health and safety risk to resident who went to the emergency room and was diagnosed as hypoglycemic.
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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) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/16/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200916144305

FACILITY NAME:NORA'S HOME CARE #2FACILITY NUMBER:
347000947
ADMINISTRATOR:BERCI, ELEONORAFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVENUETELEPHONE:
(916) 536-0240
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:0CENSUS: 0DATE:
01/29/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nora Berci, Licensee and Kevin Lee, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Resident sustained injury due to lack of supervision
Unlawful eviction
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed Licensee, Administrator, House Manager, (2) staff, representative from an outside agency, and Ombudsman. LPA reviewed documentation including, but not limited to, resident's (R1's) Physician, Report, Needs and Services Plan, Medication Administration Record (MAR), medication orders Unusual Incident/Injury Reports (LIC624), hospital discharge paperwork, letter regarding change in ownership, and Designation of Facility Responsibility (LIC308).

The results of the investigation are as follows:

Allegation: Resident sustained injury due to lack of supervision.

Interviews with staff that attended to resident on 8/30/2020 indicated that resident had a cat she kept in her room and resident stated she was looking for the cat when she fell around 9:00 pm. Licensee, who cared for resident for over a year, but was not present during the incident, stated that resident was probably trying to put food out for the cats by herself or clean up from them and was leaning forward too far and fell. Licensee stated she told resident many times to ask for help from the caregivers in feeding or cleaning up from the cat(s) instead of trying to do so herself.
cont on 812C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20200916144305
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: NORA'S HOME CARE #2
FACILITY NUMBER: 347000947
VISIT DATE: 01/29/2021
NARRATIVE
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LIC624 completed for the incident notes that 2 staff were present during the shift when resident fell, and there were 5 residents at the time of the incident. Licensee stated that there are always 2 caregivers, and sometimes an Administrator, during every shift and resident was able to transfer herself independently from bed to chair and from chair to bed, and could not recall resident sustaining any previous falls. Hospital discharge paperwork and a letter from attending ER physician, dated 9/2/20, confirm that resident was treated for a fractured collarbone resulting from a fall. Interviews confirmed that resident returned to the facility with a sling, was instructed to follow up with her primary care physician, and there were no changes in resident’s care needs. Ombudsman indicated that resident stated to him that the facility "took good care of her".

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED -A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Allegation: Unlawful eviction: Resident was sent to the ER on 9/8/2020 for a change in condition. It was determined in the ER that resident had the medication, Glipizide, in her system, which was not prescribed for resident. House Manager further stated that she was told by the hospital staff that they were looking to place resident at a skilled nursing facility since she needed a higher level of care. House Manager and Administrator stated in an interview that resident was not told she couldn’t return to the facility but that they told the hospital they couldn’t take resident back if she needed a higher level of care. Resident was not available for an interview but it was confirmed that resident had been transferred to a skilled nursing facility to receive physical therapy.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED -A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided to Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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
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
09/16/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200916144305

FACILITY NAME:NORA'S HOME CARE #2FACILITY NUMBER:
347000947
ADMINISTRATOR:BERCI, ELEONORAFACILITY TYPE:
740
ADDRESS:5813 KENNETH AVENUETELEPHONE:
(916) 536-0240
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:0CENSUS: 0DATE:
01/29/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nora Berci, Licensee and Kevin Lee, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Licensee abandoned facility.
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed Licensee, Administrator, House Manager, (2) staff, representative from an outside agency, and Ombudsman. LPA reviewed documentation including, but not limited to, resident's (R1's) Physician, Report, Needs and Services Plan, Medication Administration Record (MAR), medication orders Unusual Incident/Injury Reports (LIC624), medical discharge paperwork, letter regarding change in ownership, and Designation of Facility Responsibility (LIC308).

The results of the investigation are as follows:

Administrator and House manager stated that a 60-day notice was given to each resident and provided a copy of the letter during the investigation. Letter was not dated but requested that rent checks be made out to a new payee, effective 7/1/2020. Licensee stated that the letter was issued to residents around 6/5/2020 which says, in part, “there will be a new manager who will be responsible for providing care and boarding” and “within the next few months the facility will be relicensed” and "until the relicensing process is complete, the facility will continue to operate as Nora's Home Care #2". Licensee stated she submitted a completed LIC308 on 6/6/2020 and licensing records confirm that Licensee emailed a completed LIC308 to the department on 6/6/2020, to report that the facility had a new Administrator. Additionally, documents showing Administrator's current certifications were provided at that time. Interview with Licensee and House Manager revealed that the new Administrator took over and the Licensee was “not involved much” during the ownership transfer. Licensee stated that she told the new Administrator to call her with any problems during the transition.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Exit interview. Copy of report provided to Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6