347002577-9-10-2020-27-AS-SCAA-BTBSYC-20200910141719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002577
Report Date: 09/10/2020
Date Signed: 09/10/2020 02:17:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ELDERLY INN II		FACILITY NUMBER:	347002577
ADMINISTRATOR:	ROBERT TIF		FACILITY TYPE:	740
ADDRESS:	5210 ROBERTSON AVENUE		TELEPHONE:	(916) 972-7003
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 4	DATE:	09/10/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Emilia Ardelean, Licensee and Robert Tif, Administrator		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced on 9/10/20 to conduct a case management visit to follow up on a substantiated allegation of neglect and to issue a civil penalty. LPA contacted Licensee by phone and requested Licensee meet LPA at the facility shortly to discuss in detail the purpose of today's visit. LPA wore an N95 mask and was screened per Covid-19 precautionary measures upon entry. On March 15, 2019, the Department concluded a complaint investigation and substantiated the following allegations: staff neglect resulted in a resident (R1) requiring hospitalization; R1 sustained unexplained pressure injuries while in care; and facility staff did not seek timely medical care for R1. The licensee was cited four times for violating the following sections of the California Code of Regulations (CCR), Title 22, § 87464 (f)(1) Basic Services – (f) Basic services shall at a minimum include: (1) Care and supervision as defined in § 87101(c)(3) and Health and Safety Code § 1569.2(c). The facility did not provide proper care and supervision of R1, which lead to R1 sustaining pressure injuries. Additionally, the licensee was cited for CCR, Title 22, § 87466 Observation of a Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on documentation and interviews the facility failed to observe change in conditions of R1. cont on 809C(1)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ELDERLY INN II	FACILITY NUMBER: 347002577
	VISIT DATE: 09/10/2020

NARRATIVE

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809C(1)...Additionally, the licensee was cited for CCR, Title 22, § 87615 (a) Prohibited Health Conditions - Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. Based on records review and staff interviews, R1 sustained pressure injuries and prohibited health conditions. According to the National Pressure Injury Advisory Panel (NPIAP), “a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful.” Finally, the licensee was cited for CCR, Title 22, § 87465(a)(1) 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: (1) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. The licensee did not to seek timely medical treatment for the R1.

The Department’s investigation revealed in early October 2018, the licensee, Administrator, and facility staff were aware of a sore on R1’s coccyx. After R1’s conservator instructed the Administrator to take R1 for medical treatment for the sore, the Administrator made an appointment with R1’s physician. However, during that appointment on October 11, 2018, the Administrator did not mention the sore to the Nurse Practitioner and, R1 was not examined for a pressure injury.

cont on 809C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ELDERLY INN II	FACILITY NUMBER: 347002577
	VISIT DATE: 09/10/2020

NARRATIVE

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809C(2)...The Administrator took R1 to the physician on November 2, 2018 after staff had informed the Administrator that R1 “did not look good.” R1’s physician diagnosed R1 with stage 4 pressure injuries on left hip and sacral region (coccyx), stage 2 pressure injury on right hip and skin tear on left wrist. Records and photographs reviewed by the Department revealed the pressure injury to R1’s left hip to be approximately four centimeters wide by seven centimeters long (4cm x 7cm). R1 also had a stage 4 pressure injury of the sacral region (coccyx). Records and photographs reviewed by the Department described the pressure injury size as approximately five inches long by three inches wide (5cm x 3cm).

R1’s physician instructed Administrator to immediately take R1 to the hospital. During an interview with the Department, the ER physician who examined R1 on November 2, 2018 stated that the pressure injury on R1’s sacrum was advanced, had a foul smell, and was down to the bone. R1’s physician determined R1 required immediate hospitalization. Medical records indicate that after being admitted at the hospital on November 2, 2018, R1 was also diagnosed with dehydration, sepsis, gangrene, anemia, severe protein-calorie malnutrition, urinary tract infection, and skin tears on the left arm, right elbow, and right leg. According to the Mayo Clinic, “Sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems.”
R1’s ER medical records also indicate that a surgical debridement decubitus ulcer procedure was performed on R1’s pressure injuries. Mayo Clinic defines debridement as the removal of dead or infected tissue by various methods. Surgical debridement is the cutting and removal of dead or infected tissue with the use of surgical tools (e.g. scalpels, scissors). R1 was hospitalized from November 2, 2018 to November 14, 2018, after which R1 was admitted to a skilled nursing facility. ER medical records stated at discharge that R1 was in a chronic debilitated state and life expectancy may be limited. cont on 809C(3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ELDERLY INN II	FACILITY NUMBER: 347002577
	VISIT DATE: 09/10/2020

NARRATIVE

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809C(3)...R1 passed away at the skilled nursing facility on November 19, 2018.

Based on observation, interview, and record review, the licensee failed to provide adequate care and supervision of the resident and failed to seek timely medical treatment. The licensee’s failure to provide adequate care, supervision, and failure to seek timely care caused R1 to suffer stage 3 and stage 4 pressure injuries that required hospitalization, which is a serious bodily injury.

At the time of the complaint visit conducted on March 15, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, September 10, 2020, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 15, 2019, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Emilia Ardelean, Licensee, and originals were signed.
Exit interview conducted. A copy of the report issued. Appeal Rights provided. Emilia Ardelean's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC809 (FAS) - (06/04)

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