347002711-11-4-2024-27-AS-SDOB-DATMWH-20241108085823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002711
Report Date: 11/04/2024
Date Signed: 11/04/2024 10:47:13 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
08/06/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240806224550

FACILITY NAME:	TRINITY CARE HOME		FACILITY NUMBER:	347002711
ADMINISTRATOR:	ENRIQUEZ, HELEN		FACILITY TYPE:	740
ADDRESS:	9513 WADENA WAY		TELEPHONE:	(916) 683-9096
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Helen Enriquez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident suffered a fracture due to staff neglect

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Helen Enriquez and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed Enriquez, five staff members (S1-S5), five residents (R1-R5), a case worker assigned to R1, and a home health nurse assigned to R1.

LPA Moleski was informed by Enriquez that R1 had suffered a fracture to their right upper arm around the date of July 19, 2024. Enriquez had no documentation available regarding this injury, such as an incident report or other medical documentation, and no additional documentation regarding this resident. These deficiencies were previously addressed during a case management visit on 8/12/24. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

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 27-AS-20240806224550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TRINITY CARE HOME	FACILITY NUMBER: 347002711
	VISIT DATE: 11/04/2024

NARRATIVE

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LPA Moleski received an incident report regarding R1’s injury on 8/12/24. The incident report stated that Enriquez was notified by a caregiver on 7/19/24 that R1 was complaining of right arm pain. R1 was taken to a hospital for treatment on that same date, according to the incident report.

In an interview, Enriquez said that R1 did not fall, and did not suffer any other unusual injuries leading up to the discovery of the injury. She said her caregivers were made aware of the injury as described in the incident report when R1 started crying out when moving their arm in the shower. Enriquez said that R1 suffers from severe aphasia and is unable to articulate themselves well. However, she said that she asked the resident if they fell, to which they responded in the negative.

LPA Moleski interviewed R1 at a skilled nursing facility. R1 was not able to speak clearly or elaborate upon their answers. However, when asked, R1 indicated that they had not fallen, and had not been abused or otherwise injured by staff while residing at this facility. When asked, R1 indicated that they did not know how they suffered the fracture.

In interviews with all other residents of this facility (R2-R5), none indicated that they had observed any falls suffered by R1, and none had any pertinent information to share regarding the cause of R1’s injury.

In interviews, no staff members (S1-S5) were able to provide pertinent information regarding the cause or circumstances surrounding R1’s injury. None of the staff interviewed had witnessed any falls immediately prior to the discovery of R1’s injury, and none of them had observed any physical abuse being perpetrated by other staff members. S1 said that R1 had never fallen, but said that they had observed R1 sleeping on their arm, potentially causing strain. S1 said they discovered the injury when R1 started repeating the word “hurt” while showering. S1 said that the administrator was called and R1 was sent to the hospital afterward.

In an interview, R1’s home health nurse said that they suspected some sort of physical trauma had occurred in order to cause the injury, but had not observed any physical abuse being perpetrated by staff of this facility, and was not aware of any falls suffered by R1 while living at this facility. [continued 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240806224550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TRINITY CARE HOME	FACILITY NUMBER: 347002711
	VISIT DATE: 11/04/2024

NARRATIVE

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In an interview, R1’s case manager said that medical documentation on file showed that R1’s injury was initially classified as pathological, but it was later determined by medical personnel that the injury was suspicious.

The department has determined the following as it relates to the allegation that a resident suffered a fracture due to staff neglect:

Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which 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.

No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Enriquez.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024

LIC9099 (FAS) - (06/04)

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