<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003426
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:07:14 PM


Document Has Been Signed on 01/24/2024 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:DEL VISTA RESIDENTIAL CAREFACILITY NUMBER:
347003426
ADMINISTRATOR:SAEL, TATY L.T.FACILITY TYPE:
740
ADDRESS:78 DEL VISTA CIRCLETELEPHONE:
(916) 690-7243
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
01/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Taty SaelTIME COMPLETED:
12:30 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
On 1/24/2024 at 11:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. During the course of the investigation in to complaint control number 27-AS-20230712160817, another deficiency was identified which is being addressed by this case management. LPA Villanueva met with Taty Sael, Administrator, and explained the purpose of the visit. During today’s visit, present were 3 residents in care with 2 staff on duty.

During the course of the investigation for above listed complaint, file reviews were conducted. A review of R1’s care notes dating 07/02/23 indicates R1 “started coughing lastnight…saying she cannot breath…, 07/03/23 R1 did not have a good nights sleep lastnight, 7/07/2023 indicates that R1 was having difficulties sleeping the past 3 nights due to coughing. Additionally, R1 was noted to have hard time breathing with O2 level measured at 65. It was also noted that the administrator found R1’s right lower arm to be swollen and red/bluish. Administrator notified clinic physician via phone and was ordered Albuterol nebulizer increased to 6 times every 4 hours as needed. Also prescribed cough syrup 4 times daily and antibiotic to start on this date.

Further review of R1’s care notes dating 7/9/2023 indicates that R1’s right arm (dialysis port) continues to be bleeding. It was noted that care staff did not change the dressing on the wound. On 7/10/2023 of the care notes, it was noted that care staff notice R1’s nose to be bleeding and a bruise on the corner of R1’s mouth was noted. It was also noted that R1’s physician was notified and a plan to send R1 to the hospital due to bleeding on R1’s nose and dialysis port. L PA cannot confirm from the R1’s note if R1 was sent to the hospital. By this time, R1’s condition appeared to have worsened.

Although a physician was contacted on 7/7/2023 and medications were prescribed, the licensee did not ensure timely medical attention for R1 due to R1’s breathing problem with O2 stat level at 65. Additionally, R1’s change in condition worsened on 7/10/2023.

{Con't to LIC809-C}

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/12/2024 12:08 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/12/2024 10:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: DEL VISTA RESIDENTIAL CARE
FACILITY NUMBER: 347003426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2024
Section Cited
CCR
87465(a)(2

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed... (2) The licensee shall provide assistance in meeting necessary medical and dental needs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to submit a written program plan revision via an addendum to develop a new policy to ensure residents obtain timely medical attention.

Policy to be submitted to the Department no later than POC due date 1/25/2024.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not ensure medical attention is sought timely for R1. R1 did not receive medical attention in a timely manner when changes in condition were observed that warrant hospitalization. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
01/31/2024
Section Cited
CCR87211(a)(1)

1
2
3
4
5
6
7
Reporting Requirements 87211(a) (1) Each licensee shall furnish to the licensing agency such reports as the Department may require.. A written report shall be submitted to the licensing agency and to the person responsible ...This requirment was not met as evidence by:
1
2
3
4
5
6
7
Licensee/administrator agree to conduct reporting requirement training for all staff. All training material and sign in sheet shall be emailed to LPA Villanueva by POC Date 1/31/24.
8
9
10
11
12
13
14
Based on interviews and file review, the licensee/administrator did not ensure all reporting requirments was met, as facility administrator did not submit incident reports of R1 on 8/24/22, 2/22/23, and 3/23/23 to the Department. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DEL VISTA RESIDENTIAL CARE
FACILITY NUMBER: 347003426
VISIT DATE: 01/24/2024
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
26
27
28
29
30
31
32
{Con't from LIC809}

During a review of R1's care notes, LPA Villanueva read that R1 was sent to emergency hospital on the following dates: 8/24/22, 2/22/23, and 3/23/23. Per interview with the administrator, incident reports on these incidents were not reported to the Department.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty in the amount of $500 is assessed in addition to the citations issued. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

An exit interview was conducted with Taty Sael, administrator and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3