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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004078
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:24:17 PM

Document Has Been Signed on 08/31/2023 04:24 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:BHI-RUSH CREEK HOMEFACILITY NUMBER:
347004078
ADMINISTRATOR:THELMA ENRIQUEZFACILITY TYPE:
735
ADDRESS:9467 RUSH CREEK COURTTELEPHONE:
(916) 685-3776
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
08/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Thelma Enriquez TIME COMPLETED:
04:45 PM
NARRATIVE
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On 8/31/23 at approximately 2:30pm Licensing Program Analysts (LPAs) Jennifer Fain and Maya Jensen arrived at facility unannounced to conduct a case management related to an Incident Report received for resident 1 (R1). LPAs met with Licensee Thelma Enriquez and explained the purpose of today's visit.

LPAs interviewed Administrator and reviewed resident file. Based on interview and file review resident was at the facility with a stage 4 pressure wound until he was admitted to the hospital on 8/17/23. Stage 3 and 4 pressure wounds are prohibited conditions.

During the course of the file review it was also noted that the IPP was dated 1/6/22.

Technical Advice was given on pressure wounds and a pressure wound guide was given to administrator,

Pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were observed and cited on the LIC 809D

An exit interview was conducted, and a copy of this report, LIC 811 and appeal rights was provided to administrator..

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 2
Document Has Been Signed on 08/31/2023 04:24 PM - It Cannot Be Edited


Created By: Jennifer Fain On 08/31/2023 at 03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BHI-RUSH CREEK HOME
FACILITY NUMBER: 347004078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
82091(a)(4)

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(a) Clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (4) Stage 3 and 4 pressure sores. This requirement was not meet as evidenced by:
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Licensee agrees to have an outside vendor conduct training on pressure wounds for all staff on pressure wounds. Training will be scheduled by 9/1/23 and completed by 9/29/23. Proof of correction will be emailed to jennifer.fain@dss.ca.gov by POC date.
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Based on file review, observation and interview the licensee did not ensure resident was assessed and the wound progressed to a stage 4 before he was moved to an appropriate care facility for his needs. This poses an imediate risk to the health, safety and personal rights of residents in care.
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Type B
09/29/2023
Section Cited
CCR80068.2(b)(1)

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Needs and Services Plan(1) The needs appraisal or IPP is not more than one year old.This requirement was not meet as evidenced by:
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During the course of the visit the licensee contacted the Regional Center for an updated IPP. No other correction is needed.
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Based on file review, observation and interview the licensee did not have an updated needs and services plan. This poses a potential risk to the health, safety and personal rights of the residents in care.
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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:Liza King
LICENSING EVALUATOR NAME:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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