347002045-5-18-2023-59-AS-MSEY-CS3N4G-20230522100751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002045
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:48:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
04/03/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230403110023

FACILITY NAME:	COUNTRY OAKS MANOR		FACILITY NUMBER:	347002045
ADMINISTRATOR:	ALEKSANDER MOLITVENIK		FACILITY TYPE:	740
ADDRESS:	7595 LINDEN AVENUE		TELEPHONE:	(916) 726-7110
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 4	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Alek Molitvenik, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Residents needs are not being met due to a lack of staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation. LPA met with Alex Molitvenik, Administrator, and explained purposer of inspection. LPA observed (2) residents in the common area and (2) residents to be resting in their rooms. There are currently (4) residents residing at the community. The facility is approved for (6) non-ambulatory residents.

Durinig the inveestigation, LPA interviewed Administrator, (1) staff and reviewed documentation related to staffing schedules, pre-appraisals and physician's report for (4) residents (R1-R4).

The results of the investigation are as follows:

The complaint alleges that staff has to focus so much attention on (1) resident that the needs of other residents cannot be met.

Administrator stated he is at the facility at least 4-5 hours daily and from 6 am- 9 pm once weekly. In additionl, there is a live-in staff that works at the facility, 6 days per week. Administrator stated that in addition to him and the live-in caregiver, there are other individuals on-call for night coverage, if needed. LPA observed names of additional staff listed on the LIC500 that are noted as being "on-call".
**cont on 9099C(1)...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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 59-AS-20230403110023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: COUNTRY OAKS MANOR	FACILITY NUMBER: 347002045
	VISIT DATE: 05/18/2023

NARRATIVE

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9099C(1).. Administrator stated that all residents receive at least (2) showers weekly, and more if requested, and he will assist in giving showers, and a shave. . Additionally, residents' laundry is completed daily. There was no shower documentation available to review, but Administrator will document now. R4 receives care, including showers, from hospice nurses, several times per week. Residents receive (3) meals daily with snacks also, and assistance with toileting is provided when needed. LPA did not observe any odors to be present in the facility on 4/16/23 or on 5/18/23 when conducting an inspection.

LPA reviewed physician's reports for residents (R1-R4). Resident (R1) is the only resident with a diagnosis of Dementia and the physician's report was last updated 4/23/23. Physician's report for R1 notes resident is confused, ambulatory and wanders.

Physician's reports for residents (R2-R3) note residents have a diagnosis of Mild Cognitive Impairment. Reports were dated from 2020 and 2017. Administrator stated he has attempted to get updated reports multiple times but has been unable to. Administrator agreed to ask Conservator to reach out again and request an update for the last medical appointment and maintain in resident's file. Resident (R4) remains on hospice at this time.

Administrator stated that none of the (4) residents are regularly awake at night. Administrator commented "(R1) sleeps pretty good,, (R2) doesn't get up and R3 will stay up until 11 pm- 12 am." There were (6) residents about a month ago, but one resident who was only at the facility for (2) weeks . Another resident went to a higher level of care. Administrator advised to always ensure there is sufficient staffing to meet resident's needs.
LPA toured the facility and observed each room to be clean, odor free and with clean laundry folded. LPA also trash cans to be emptied and a load of laundry that was recently washed ready to be placed in the dryer.

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 Administrator. A copy of updated license showing hospice approval for (4) was printed today.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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