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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002248
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:48:59 PM

Unsubstantiated


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
07/12/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220712125821
FACILITY NAME:RODNEY KEINATH COUNTRY HOMEFACILITY NUMBER:
347002248
ADMINISTRATOR:KEINATH, RODNEYFACILITY TYPE:
735
ADDRESS:8267 CHESTER DRIVETELEPHONE:
(916) 682-9485
CITY:SACRAMENTOSTATE: CAZIP CODE:
95830
CAPACITY:6CENSUS: 6DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ester Olivia MaramisTIME COMPLETED:
03:13 PM
ALLEGATION(S):
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Staff mishandled the clients medications while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez and Arielle Pascua arrived at the facility unannounced on 07/28/2022 at 2:30 pm to deliver complaint findings, LPA met with Ester Olivia Maramis and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed facility documents. LPA Martinez reviewed four out of four residents' medication administration records (MAR). LPA reviewed June 2022 and July 2022 MAR sheets. LPA Martinez observed MAR sheets were being signed by care staff daily. It was learned medications were being administered daily per doctor's doseage orders. However, resident 1 (R1) and resident 2 (R2) MAR sheets did not accurately reflect current medication dosage orders. Staff did not correctly discontinue medication order on MAR sheets, and did not create a new medication doseage order entry on MAR sheets.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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 2
Control Number 27-AS-20220712125821
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: RODNEY KEINATH COUNTRY HOME
FACILITY NUMBER: 347002248
VISIT DATE: 07/28/2022
NARRATIVE
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Due to the above noted information, there was not enough evidence to prove residents' medication were being mishandled. However, the facility did not ensure to maintain accurate MAR sheets. As result, A case management was conducted and cited for not maintaining MAR sheets. The deficiency can be found on the case management visit.

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 did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the 809 report was given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2