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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 11/05/2020
Date Signed: 11/05/2020 04:29:23 PM



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
06/04/2020 and conducted by Evaluator Anthony Tuck
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200604093525
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
11/05/2020
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:ERMELINDA SIEBENTHALTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff are not meeting the resident's diapering needs

Facility staff are using restraints on resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anthony Tuck called the facility on 11/05/2020 at 4:00pm LPA spoke with Administrator (AD) Ermelinda Siebenthal to deliver findings and close complaint investigation. LPA conducted investigation by visiting the facility on 06/09/2020, LPA interviewed Administrator, other Resident, and Residents Responsible Party at facility. LPA interviewed Hospice Nurse Aide 06/25/2020, LPA obtained photographs of alleged violations along with copies of weekly fluid intake, Appraisal/needs service plan, physician report and pertinent documents such as communication letters faxed to the doctor. email communications from responsible party and administrator and copies of medical appointment summary for resident. Based on the investigation, LPA found the administrator failed to ensure that the resident was checked throughout the night for incontinence care from photographs provided by the hospice care nurse showing that the resident is being placed in a diaper and a pull-up and found soaked through each morning when hospice care comes to tend to the resident. LPA obtained a copy of the fluid intake for the resident indicating fluid intake for morning evening and night. The administrator also admits to placing a diaper and a pull up on the resident during the interview.
9099 continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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 3
Control Number 27-AS-20200604093525
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2020
Section Cited
CCR
87608(a)(3)
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Postural Supports (a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require ... documentation ... This requirement was not met as evidence by:
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Licensee has obtained written approval from physician and will send attachment to LPA via email on 11/06/2020.
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The administrator failed obtain a written order from physician for use of a postural support strap prior. Based on information gathered through interviews, Administrator used postural support without approval from physician. This poses a potential health risk to residents in care.
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Type B
09/18/2020
Section Cited
CCR
87625(b)(2)(3)
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Managed Incontinence (b)(2)(3)
Facilities shall ensure that incontinent residents are checked during those periods of time when they are known to be incontinent... Facilities are to ensure that incontinent residents are kept clean... This requirement was not met as evidence by:
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Licensee has hired additional staff for overnight rounds to managed incontinence care and is now changing residence every 3 hours. Licensee will send copy of overnight schedule to LPA to show proof of correction for managing incontinence care via email on 11/06/2020.
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 The Administrator failed to ensure that the resident was checked for incontinence care throughout the night and kept clean and dry. Based on information provided through interviews, resident was found in the morning soaked with urine. This poses a potential health risk to residents in care.
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Licensee has also conducted additional training for all staff on incontinence care and will provide copy of training to LPA via email on 11/06/2020.
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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200604093525
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 11/05/2020
NARRATIVE
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LPA was informed by the administrator during the interview that she failed to obtain approval from a medical physician for use of a postural support prior to use with resident.
LPA obtained additional documentation from an email communication sent from the administrator that approval for the support strap was given by the doctor after the complaint had been filed.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-D, and appeal rights were received. Administrator is to print out each report, sign it, and fax a signed copy to LPA at 916-263-4744
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3