347001078-8-6-2024-27-AS-KHOS-D83PQ9-20240812113047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001078
Report Date: 08/06/2024
Date Signed: 08/06/2024 10:37:50 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240531091131

FACILITY NAME:	COURTYARD TERRACE		FACILITY NUMBER:	347001078
ADMINISTRATOR:	MAGDA LUIS		FACILITY TYPE:	740
ADDRESS:	3408 ALTA ARDEN EXPRESSWAY		TELEPHONE:	(916) 486-1281
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	40	CENSUS: 39	DATE:	08/06/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Magda Luis		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Magda Luis, and explained the purpose of the visit.

The following has been determined as it relates to the allegation of Resident sustained an unexplained injury while in care. The investigation consisted of an interview with the Reporting Party (RP), interview with Resident 1 (R1), interviews with Staff 1 (S1) - Staff 2 (S2), and records review.

According to an interview with the RP, the RP stated R1 had a bruise all over R1's face. RP did not know when it happened, and was not present when it happened. RP heard it when R1's family member got a call from the facility. RP does not know how it could happen when R1 is able to walk and has never fallen. RP is not listed as a responsible party for R1.
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240531091131

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTYARD TERRACE	FACILITY NUMBER: 347001078
	VISIT DATE: 08/06/2024

NARRATIVE

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Continued from LIC 9099..

According to an interview with R1, R1 does not remember how a mark got on R1's face. R1 told LPA Valerio multiple times it does not work. R1 stated R1's responsible party took R1 to the doctor. R1 told LPA that R1 does not need to use the walker that was next to R1's bed. R1 enjoys the facility and reports staff are nice.

During the interview on 06/03/2024, LPA Valerio observed R1's face. R1 was observed to have a red mark on the right cheek located at the top of the cheek bone. The red mark was not accompanied by any discoloration. R1 was not observed to have any scratches on the face. R1 was not observed to have any bruises on arms, face, or left leg.

LPA Valerio interviewed two (2) staff members that were present during the incident. Staff 1 stated the incident was unwitnessed. S1 asked R1 what happened. R1 told S1 that R1 was going to the bathroom and hit the door. R1 stated no fall happened. S1 notified the medication technician right away. S1 said R1's family member came, took R1 to the doctor, and came back stating everything was fine. S2 reported that R1 was seen to have scratches on the face with a bruise. S2 stated it happened in the morning time. S2 could not get a hold of R1's family until the afternoon when they picked up the phone. S2 stated R1 does not know what happened but has reported to be fine and does not complain of any pain.

LPA Valerio reviewed facility records. Facility records show that during AM shift on 05/27/2024, R1 was noticed to have a red spot on R1's face. A medication technician was immediately notified to assess R1. The medication technician applied ointment to the cheek and notified the family. According to facility records, the resident sign out sheet showed that the family member arrived to the facility on 05/30/2024 and signed out R1 at 12:30 PM. R1 was returned to the facility at 7:30 PM.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility with Administrator Magda.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC9099 (FAS) - (06/04)

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