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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002045
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:27:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
05/18/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230518135637
FACILITY NAME:COUNTRY OAKS MANORFACILITY NUMBER:
347002045
ADMINISTRATOR:ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 726-7110
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kenisha TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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 Staff did not dispense medication to resident for several days
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint invetigation for a complaint received on 5/18/23. LPA met with Khnesha Hylton, caregiver, who contacted
Alex Molitvenik, Administrator, by phone and explained purposer of inspection. Administrative said he would arrive in (20) minutes. LPA observed (2) residents to be in the common areas and (2) residents to be in their rooms at the start of the inspection.

During the investigation, LPA interviewed the Administrator, a primary caregiver (S1) and (2) representatives from the Veterans Administration (VA) and reviewed pertinent documentation related to resident (R1). (R1) lived at the faciity from around 3/28/23 through 5/12/23. The complainant was anonymous and was not able to be contacted for additional information.

The results of the investigation are as follows:
cont on 9099C-1...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
05/18/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230518135637

FACILITY NAME:COUNTRY OAKS MANORFACILITY NUMBER:
347002045
ADMINISTRATOR:ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 726-7110
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kenisha TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Administrator prompting what resident should report to representative during telephone conversation-UNSUB
Staff did not provide nutritious meals to resident in care- UNSUB
Administrator did not obtain refill medication for resident in care- UNSUB
Administrator did not seek medical attention for resident in care
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed the Administrator, a primary caregiver (S1) and (2) representatives from the Veterans Administration (VA) and reviewed pertinent documentation related to resident (R1). The results of the investigation are as follows:

Allegation: Administrator prompting what resident should report to representative during telephone conversation. Complaint alleges that R1’s POA heard licensee Alex, in the background, prompting resident (R1) to say he was eating chicken when (R1) said he had pizza which he is not supposed to have.

The Administrator stated the POA called him around/after lunch because she was upset that (R1) didn't pick up the phone and asked the Administrator what (R1) was "eating right now". The Administrator explained that when he told the POA (R1) had pizza for lunch, she got mad, and asked why he was given pizza for lunch.

cont on 9099A-C1...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20230518135637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045
VISIT DATE: 09/08/2023
NARRATIVE
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9099A-C1...The Administrator stated (R1’s) POA called (R1) a second time, on 5/11/23, during dinner, while (R1) was eating/chewing and so he answered the phone for (R1) and told (R1) the POA that (R1) was eating chicken. The Administrator confirmed that (R1) was served pizza for lunch and chicken with salad for dinner on 5/11/23.

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: Staff did not provide nutritious meals to resident in care.
Complaint alleges that (R1) was admitted to hospital because the facility was not giving (R1) his medication and he was feeding him improperly.

Primary staff (S1)confirmed that (R1) did have a "special diet" that included "less bread" and less potato and rice, stating "once a week we would give him frozen pizza"- usually on Thursdays when the Administrator is here. (S1) confirmed the facility serves a "routine menu" which includes serving oatmeal twice weekly on Wednesdays and Saturdays and cold cereal on Tuesdays and Fridays.

The Administrator also confirmed that (R1) had a "special diet" and staff would serve meals with "low carbs and usually less bread and carbs" due to (R1’s) diagnosis of Diabetes. The Physician’s Report, dated 3/3/23, indicates that (R1) needs a special diet consisting of low carbs. The Administrator confirmed that he served (R1) pizza on Thursday, 5/11/23, which was the scheduled lunch meal that day. The Administrator stated that he picked up medication refills, in person, at the pharmacy on 5/9/23 and medication was administered as scheduled following picking up the medications.

LPA observed fresh produce on hand on 9/8/23.

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.



cont on 9099A-C2...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20230518135637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045
VISIT DATE: 09/08/2023
NARRATIVE
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9099C-2-.. Allegation: Administrator did not obtain refill medication for resident in care. Complaint alleges that the Administrator did not tell the POA that (R1) needed his medication refilled and the Administrator did not refill his medication.

The Administrator stated that (R1) missed scheduled medications starting on 4/28/23, due to not receiving the refills in the mail, stating he called the VA on Mon, 5/8/23, and picked up the meds on Tues, 5/9/23. The Administrator asserted that (R1) "always had an insulin pen" but "ran out of pills for approximately two weeks".

A representative with the VA stated to LPA that they do not offer the option of “automatic refills” and a medication refill must be requested online, if there are refills available, or by phone, if there are no remaining refills. The representative explained the veteran or the caregiver can go online to their website to request the refill.

Administrator stated called on/around 4/21/23 and requested refills of multiple medications, 7 days before the medications would run out. On 5/8/23, the pharmacy left a message that the medications mailed had returned due to a wrong address.

LPA was not able to confirm any specific information with the VA pharmacy without a signed consent due to HIPPA. (R1) does not live at the facility any more and the complainant was anonymous.

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: Administrator did not seek medical attention for resident in care. Administrator did not see that (R1’s) condition was changing, his sugar was high, and he had not had his medication.

A primary caregiver (S1) stated Wednesday, 5/10/23, he observed (R1) to be "shaky" and "declining a bit". (S1) indicated he was not working on Thursday, 5/11/23, as it was his regular day off, but he returned and was back on shift on 5/11/23 around 8:30-9:00 pm. (S1) stated that (R1) was watching television and went to the bathroom by himself and (S1) told him to "lay down", stating 10-15 minutes later, (R1) was "still on the toilet and he was very confused".
cont on 9099C-3..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20230518135637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045
VISIT DATE: 09/08/2023
NARRATIVE
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9099C-3.. (S1) indicated that resident (R1) was sent to the Emergency Room on 5/12/23, when he was working. (S1) explained that he observed (R1) Friday morning, around 7:30 and (R1)'s condition was "more serious" and was "shaking every minute and more confused" so he called the Administrator. (S1) explained that (R1) was not able to give himself the normal insulin injection. (S1) explained that the Administrator called 9-1-1 around 8:15 am as (R1’s) condition "definitely got worse" and this was right before the daughter called. (S1) commented that on Wednesday, 5/10/23, (R1) "seemed at baseline" and then on "Friday morning, I really noticed" a change.

The Administrator stated that (R1) was seen by a home health nurse on Thursday morning, 5/11/23 and (R1) was appearing to be a "little confused" at that time, but the nurse who checked him said it wasn’t necessary to call 9-1-1 but to monitor (R1). The Administrator stated (R1) was "not like usual but it was not alarming".

Documentation shows that (R1’s) blood sugar was taken in the morning on 5/11/23 and was “200”. It was not taken again until the morning of 5/12/23, when it read “225”. (R1’s) blood sugar measured “147” on 5/9/23 and “157” on 5/10/23.

Administrator stated (R1's) blood sugar was around 140-160 usually in the morning but it was high around 200-225 on 5/10/23 and 5/11/23 after receiving the refilled medications. (R1) was admitted to the hospital on 5/12/23.

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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20230518135637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045
VISIT DATE: 09/08/2023
NARRATIVE
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9099C-1.. Allegation: Staff did not dispense medication to resident for several days. Complaint states that when the POA told the Administrator that (R1) would not be returning to the facility, the Administrator indicated (R1) did not have his medication for a couple of days.

The Administrator stated that usually (R1’s) medications are sent by regular USPS and are received within 5-7 days and confirmed that the VA would send a 30-day supply of each medication and they usually reach out when they are mailed. The Administrator stated that he phoned in a refill for multiple medications on/around 4/21/23 when there was approximately (7) days supply remaining on the medications. Administrator stated that when the medications had not arrived by/around 4/28/23, he called the VA pharmacy again and (R1’s) POA to advise the medications were late and was informed by the pharmacy the medications were sent to a prior address for (R1). (R1’s) POA indicated she would look into the address VA had on file and request it be updated.

On 5/19/23, LPA listenedd to a voice message received on the facility land line on 5/8/23 from the "outpatient pharmacy" at the VA Mather location. LPA heard the caller state that "the prescription was mailed but returned back to us" and advised the Administrator to contact them at the number provided. The Administrator stated that on the morning of 5/9/23, he went to pick up the medications in person at the VA pharmacy, and (R1) was then administered medications as scheduled. The Administrator confirmed that (R1) did not have scheduled medications from on/around 4/28/23- 5/9/23; however, he always had a supply of insulin. The facility does not maintain a Medication Administration Record (MAR) currently.

The Administrator stated that (R1’s) son picked up his belongings, including unused medications on 5/17/23 and an ending medication inventory count was not taken but the bottles were almost full since they had been picked up on 5/9/23. There is a separate citation issued for this deficiency.

The Administrator stated that (R1’s) physician was not contacted to advise (R1) did not receive medication during the (2) week period because it is difficult to get in contact with VA physicians, but the pharmacy was aware and the POA was also.

LPA finds the allegation to be SUBSTANTIATED- meaning that the allegation is valid because the preponderance of the evidence standard has been met.



The following deficiencies (2) are cited per Title 22 and the Health and Safety Code. Appeal Rights provided, exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20230518135637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87465(a)(4)
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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:
(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee/Administrator agree to read regulation 87465 and submit a signed statement of its understanding and also to consider using a Medication Administration Record (MAR) to log every dosage that is administered.
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Based on interviews conducted and documentation reviewed, the LIcensee did not ensure that (R1) was administered scheduled medications, from approximately 4/28/23 through 5/9/23 (morning), while waiting for the medications to be delivered, which posed an immediate health and safety risk to residents in care.
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Documentation to be submitted to the Dept by 9/11/23 by email/Fax.
Type B
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Section Cited
CCR
87465(i)
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87465 Incidental Medical and Dental Care
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement is not met as evidenced by:
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Licensee/Administrator agree to read regulation 87465 and submit a signed statement of its understanding. Admin agrees to review all current residents' files and ensure that all medication is written on the LIC622.
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Based on interview, the Licensee did not document an ending medication inventory and obtain a signature when (R1's) medications were picked up on 5/17/23. The medications picked up on 5/9/23 were not logged on the LIC622-
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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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7