347002577-2-5-2021-27-AS-KHOS-BY5JG9-20210211060155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002577
Report Date: 02/05/2021
Date Signed: 02/05/2021 10:17:22 AM

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
07/02/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200702161524

FACILITY NAME:	ELDERLY INN II		FACILITY NUMBER:	347002577
ADMINISTRATOR:	LEAL, RUBEN		FACILITY TYPE:	740
ADDRESS:	5210 ROBERTSON AVENUE		TELEPHONE:	(916) 972-7003
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 0	DATE:	02/05/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robert Tif, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility staff neglected resident resulting in infection and hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted Robert Tif, Administrator, by phone to deliver findings to a complaint investigation received on 7/2/2020. Findings are being delivered by phone due to current Covid-19 precautionary measures in place. Currently there are no residents at the facility location as there is a pending ownership change.

During the course of the investigation, the department interviewed resident (R1), resident's family members, Home Health nurse and staff, former caregiver, and facility Administrator. The department reviewed documents including, but not limited to, hospital medical records, home health records, physician report, and needs and services plan.

The results of the investigation are as follows:

Allegation: Facility staff neglected resident resulting in infection and hospitalization.

Administrator Robert Tif stated on 6/30/2020, around 4:00 pm, he noticed resident had not urinated since lunch time and resident had had a normal amount of urine output in the morning. Administrator stated he was watching resident closely due to resident having a history of UTI, due to using a catheter. Resident's physician's report, dated 6/6/2020, notes resident's primary diagnosis to be Urinary Tract Infections. Administrator called 911 because resident had also developed a fever, and then vomited. Administrator stated to the department that he told paramedics that resident had not urinated for two hours, not two days, as it was reported by paramedics to hospital staff.
cont on 9099C..

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: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

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 4

Control Number 27-AS-20200702161524

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: ELDERLY INN II	FACILITY NUMBER: 347002577
	VISIT DATE: 02/05/2021

NARRATIVE

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9099C...Resident had a home health nurse who visited once or twice a month and changed resident's catheter bag; however, home health care was discontinued in early June 2020 due to resident meeting their goals. There were no facility records or logs documenting resident's home health care visits, when facility staff emptied the catheter bag, or the amount of urine staff emptied from the bag. (See 809D issued 2/5/2021 for citation issued). Resident was due to have the catheter changed a week earlier but it was never done. Resident had a visit with Home health care nurse on 6/25/2020 and there was no mention of a catheter change.

Review of hospital medical records show that resident was admitted on 6/30/2020 for sepsis and a UTI, and resident's catheter was "caked with sediment", was odorous, and had 20 ml of dark urine in bag. The bag was leaking and 1500 ml of urine "gushed" out when the existing catheter was removed. Interview with a nurse supervisor, indicated that patients are typically seen once a month for catheter care and 1500 ml of urine is a full bag, and it would be impossible to create that much in two hours, but it is also not two days of urine. The nurse supervisor said depending on how much water one was drinking, it is about half a day's worth of urine and from a nursing standpoint, they want to see 300 ml per hour.

Hospital medical records further document that resident presented from board and care "for catheter malfunction". Resident was treated for a UTI and was discharged and returned to the facility on 7/4/2020. No other medical issues were noted by resident's treating physician in the hospital.

Based on information obtained, the department 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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/02/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200702161524

FACILITY NAME:	ELDERLY INN II		FACILITY NUMBER:	347002577
ADMINISTRATOR:	LEAL, RUBEN		FACILITY TYPE:	740
ADDRESS:	5210 ROBERTSON AVENUE		TELEPHONE:	(916) 972-7003
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS:	DATE:	02/05/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robert Tif, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility retained a resident requiring a higher level of care
Facility staff failed to address change in resident's medical condition

INVESTIGATION FINDINGS:

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During the course of the investigation, the department interviewed resident (R1), resident's family members, Home Health nurse and staff, former caregiver, and facility Administrator. The department reviewed documents including, but not limited to, hospital medical records, home health records, physician report, and needs and services plan. The results of the investigation are as follows:

Allegation: Facility retained a resident requiring a higher level of care.

Resident pre-appraisal dated 4/26/2020 notes that resident has a history of Urinary Tract Infections (UTI) and uses a catheter due to urinary retention. Home Health records indicate that resident began receiving care on 4/22/2020, just prior to moving to board and care in late April 2020, and continued to receive home health services through 6/2/2020 for catheter care, Home Health services started up again on/around 6/6/2020 following resident being admitted to the hospital on 6/4/2020 and having a catheter placed again. Home Health Care notes document that home health care was responsible for resident's catheter care.

Based on information obtained, the department find the allegation to be UNFOUNDED- meaning the allegation was false, could not have happened, and/or is without a reasonable basis.

cont on 9099C..

Unfounded

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: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20200702161524

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: ELDERLY INN II	FACILITY NUMBER: 347002577
	VISIT DATE: 02/05/2021

NARRATIVE

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Allegation: Facility staff failed to address change in resident's medical condition.

Administrator stated that resident did not show any change in condition in the morning on 6/30/2020 and had a normal amount of urine output, but he noticed resident stopped urinating "after lunch", which is at 12:00 pm. Administrator indicated that because of resident's history of UTI, he was watching him closely. A few hours later, resident displayed a fever and then vomited, so Administrator called 911 at approximately 4:00 pm. Resident was admitted to the hospital for sepsis and a UTI, and the attending physician indicated that there were no other medical concerns noted pertaining to resident's admission other than with the catheter.

Based on information found, the department has determined the allegation to be UNFOUNDED- meaning the allegation was false, could not have happened, and/or is without a reasonable basis.

Exit interview. Copy of report emailed to Administrator who agrees to return a signed copy to the department by end of day, 2/5/2021.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

LIC9099 (FAS) - (06/04)

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