347003800-9-24-2021-25-AS-SCAA-C772WQ-20210924174556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003800
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:46:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	SENIOR GARDEN		FACILITY NUMBER:	347003800
ADMINISTRATOR:	PUNZALAN, E. VICTORIA S.		FACILITY TYPE:	740
ADDRESS:	6024 KIFISIA WAY		TELEPHONE:	(916) 723-2402
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS:	DATE:	09/24/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Victoria Punzalan, Licensee/Administrator		TIME COMPLETED:	03:00 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 September 24, 2021, Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced and met with Licensee of Senior Garden, Victoria Punzalan, at approximately 2:00 pm. Licensee confirmed there are (3) residents present. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. On April 7, 2020, the Department concluded an investigation which alleged the following: staff failed to ensure that a resident (R1) was property hydrated, and facility failed to seek medical attention in a timely manner. The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87468.2(a)(8) – Additional Personal Rights of Residents in Privately Operated Facilities which states: (a) In addition to the rights listed in § 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation , and verbal, mental, physical, or sexual abuse. Additionally the licensee was cited for violating CCR Tile 22, § 87465(g) – Incidental Medical and Dental Care which states: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstances has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in §87469(c)(2), (c)(3), or (c)(4). cont on 809C..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SENIOR GARDEN	FACILITY NUMBER: 347003800
	VISIT DATE: 09/24/2021

NARRATIVE

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During the investigation, interviews and records reviewed indicated on September 20, 2019, the facility staff believed R1 to be suffering from potential urinary tract infection (UTI). In addition, facility staff observed R1 with a change in condition which included R1 was not eating or drinking, had increased incontinence, inability to communication with staff, refusal to sit up or get out of bed, and increased aggression. Although the licensee acknowledged R1’s observed change in condition on September 20, 2019, the licensee did not seek medical attention for R1 until September 21, 2019. R1 was taken to a local hospital and admitted on September 21, 2019 and discharged September 27, 2019 on Hospice. Upon admittance to the hospital, R1 was diagnosed with UTI with Klebsiella (a urinary tract infection (UTI) is an infection in any part of your urinary system – Mayoclinic.org), severe sepsis (Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. – Mayoclinic.org), metabolic encephalopathy (Metabolic Encephalopathy is a group of neurologic disorders characterized by an alternation in mental status caused by the direct physiological consequences of a general underlying medical condition and/or pharmacogenetics. -now.aapmr.org) and acute hypernatremia (Hypernatremia is defined as a serum sodium concentration exceeding 145 mEq/L. Sodium is the most important osmotically active particle in the extracellular space and closely linked to the body’s fluid balance An increase in the serum sodium concentration is most often due to a free water deficit caused by excessive fluid loss (e.g., diarrhea/vomiting, sweating, increased diuresis) or insufficient water intake (e.g., altered mental status, impaired thirst mechanism -amboss.com). insufficient water intake poses an immediate health and safety risk to R1.

Based on observation, interview and records review, the licensee did not provide adequate assistance with hydration resulting in R1’s hospitalization and diminished capacity. Interviews indicated that the facility failed to ensure R1 was taking in an adequate amount of fluids which resulted in R1 being hospitalized. Additionally, the licensee did not seek timely medical attention for R1 which caused a delay in R1 receiving medical treatment resulting in R1’s hospitalization and sepsis diagnosis.

At the time of the case management visit on April 7, 2020, an immediate civil penalty was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety code § 1569.49.

cont on 809C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SENIOR GARDEN	FACILITY NUMBER: 347003800
	VISIT DATE: 09/24/2021

NARRATIVE

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809C(2)..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 or protracted loss or impairment of 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 24, 2021, 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 $10,000. However, since an immediate civil penalty of $500 was issued on April 7, 2020, the amount today will be $9,500.

A copy of the LIC 421D was given to Licensee, Victoria Punzalan, and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Licensee, Victoria Punzalan's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

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