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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004441
Report Date: 02/22/2023
Date Signed: 02/22/2023 03:46:00 PM

Substantiated


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
10/14/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221014114630
FACILITY NAME:COMFORT LIVING ELDER CAREFACILITY NUMBER:
347004441
ADMINISTRATOR:JESUSA NAGTALONFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
02/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Teresita Agamanos & Mariam Soumahoro TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained stage 3 and 4 pressure injuries while in care.
Facility retained resident with a prohibited health condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/22/2023 at 3:30 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Teresita Agamanos during today’s visit and Mariam Soumahoro via phone call. LPA Martinez also explained the purpose of today’s visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility records, and reviewed medical documents. Based on the investigation findings, it was determined resident 1 (R1) was admitted into the facility on 8/5/2022 with a stage three sacral pressure injury. Medical records on 9/5/2022 noted wound for R1 was closed and healed. Subsequent medical records note that R1 sustained an unstageable right heel pressure injury while in care. Moreover, R1 required assistance with maintaining their foley catheter. The complaint investigation also revealed that the facility failed to request an exception for the stage 3 pressure injuries, unstageable pressure injury and foley catheter. R1 was not receiving Hospice Care, so an exception was needed for the facility to accept and/or retain R1.
Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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
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
10/14/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221014114630

FACILITY NAME:COMFORT LIVING ELDER CAREFACILITY NUMBER:
347004441
ADMINISTRATOR:JESUSA NAGTALONFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
02/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mariam SoumahoroTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify authorized representative of change in condition.
Staff did not meet residents hygiene needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/22/2023 at 3:30 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Teresita Agamanos during today’s visit and Mariam Soumahoro via phone call. LPA Martinez also explained the purpose of today’s visit.

Throughout the course of this investigation, LPA conducted interviews and reviewed facility records. Based on facility documentation, it was learned facility staff had reported resident 1's (R1) change in condition to their responsible party on August 11, 2022, October 9, 2022. October 10, 2022, and October 11, 2022. Furthermore, facility documentation indicated a facility staff was also communicating with home health in regards R1's refusal of care. Moreover, facility records reported R1 refused showers, skin integrity checks, wound care, and catheter care. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the 9099 report was given to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20221014114630
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: COMFORT LIVING ELDER CARE
FACILITY NUMBER: 347004441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7
87615(a)(1) Prohibited Health Conditions: Persons who require health services for or have a health condition including...Stage 3 and 4 pressure injuries. This requirement was not met as evidence by: Based on observation, interviews, and file review,
1
2
3
4
5
6
7
Facility staff agrees to email LPA Martinez Prohibited Health Condition training plan by POC Date: 02/23/23 5PM. Licensee agrees to conduct Prohibited Health Condition training for all staff by POC date 03/01/23
and email training documentation to LPA Martinez by POC Date 03/01/23 5 PM
8
9
10
11
12
13
14
The Licensee retained R1 with a prohibited health condition and did not request an exception for stage 3 and 4 pressure injuries. This posed an immediate health and safety risk to R1.
8
9
10
11
12
13
14
Type A
02/23/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
 87464(f)(1)Basic Services: Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on file review,
1
2
3
4
5
6
7
Facility staff agrees to email LPA Martinez Basic Services training plan by POC Date: 02/23/23 5PM. Licensee agrees to conduct Basic Services training for all staff by POC date 03/01/23 and email training documentation to LPA Martinez by POC Date 03/01/23 5 PM
8
9
10
11
12
13
14
Observation, and interviews, the Licensee did not ensure R1's basic care needs were being met. This posed an immediate health and safety risk to R1.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221014114630
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: COMFORT LIVING ELDER CARE
FACILITY NUMBER: 347004441
VISIT DATE: 02/22/2023
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
As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. The deficiency cited can be found on the LIC 9099-D, per Title 22 Regulations.

An immediate $500.00 civil penalty shall be assessed on February 22, 2023; based on the allegation: “Resident sustained stage 3 and 4 pressure injuries while in care.” R1 sustained a stage four pressure injury, which required hospitalization, which this posed an immediate threat to the Health, Safety, and Personal Rights of R1.

An immediate $500.00 civil penalty shall be assessed on February 22, 2023; based on the allegation: “Facility retained resident with a prohibited health condition.” The facility retained R1 when they need a higher level of care, which this posed an immediate threat to the Health, Safety, and Personal Rights of R1.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments per Health and Safety Code 1569.49(e). At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4