347005512-9-13-2022-27-AS-KHOS-CJX4QS-20221005191850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 09/13/2022
Date Signed: 09/13/2022 12:15:18 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
03/30/2022 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220330095947

FACILITY NAME:	ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY		FACILITY NUMBER:	347005512
ADMINISTRATOR:	JERICA HOWARD		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108	CENSUS: 56	DATE:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	James Hall		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not answering residents call buttons timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio explained the purpose of the visit and was met by Administrator James Hall.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with staff, residents, reporting party, other witnesses, review of resident files and caregiver daily notes.

The Department has determined the following as it relates to the allegations: Staff are not answering residents call buttons timely.

Continued on LIC 9099 - C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220330095947

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
	VISIT DATE: 09/13/2022

NARRATIVE

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According to interviews, R1 pressed call button to receive assistance as described in facility service agreement and resident admission agreement. According to interviews, call button notification was not answered within the hour. According to interviews, R1 was experiencing an emergency medical occurrence. According to interview with witness, witness had to pull emergency call cord after pressing call button and getting no response. According to interview with direct witness, the facility did not answer the emergency call cord and the witness had to run through the facility to the business office to locate assistance. According to interview, call button was never answered during the emergency medical occurrence. According to interview with witness, 20 minutes had elapsed before resident was seen by staff.

According to interview with RP, R1 pressed call button on several occasions for assistance to use the bathroom. According to interviews and document reviews R1 has had to wait from as long as 20 minutes to 2 hours for response to call button for bathroom assistance. According to interviews R1 has pressed the call button for assistance on 4 different occasions whereas the call button was not answered.

According to interviews with S2 and S3, facility staff check to see if other staff is answering call buttons with the use of a walkie talkie. According to interviews, bedridden residents are waiting to get changed after pushing the call button for up to 30 minutes. In accordance with facility operation plan, and record reviews, response time to call buttons requests are targeted to be immediate and if not immediate, within a 3 to 5-minute timeframe. According to interviews with staff and residents, that time frame is not being adhered to. Therefore, residents are having to wait after pressing the call button if staff are on a break for as long as 30 minutes. Based on interviews with staff, there is a 2 to 3 ratio for caregivers and a 1 to 2 ratio of med techs in each hall at all times.

Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted with Administrator James Hall, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220330095947

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/13/2022 Section Cited CCR 87468.1(a)(16)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee stated the facility has hired additional staff, including a float staff member, fixed the call button system, and will continue to make repairs to the call button system. Licensee to send a detailed summary regarding staff plan and call button system by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure residents call button was answered in timely manner. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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