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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:48:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
05/23/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230523170557
FACILITY NAME:ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITYFACILITY NUMBER:
347005512
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 57DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Morgan WhineryTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff speak inappropriately in the presence of residents
Facility staff did not respond to residents call in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit.

This investigation consisted of interviews with Whinery, staff members (S1-S7), interviews with residents (R1-R5), and review of resident records.

During interviews, S1 described an incident where a staff member utilized a curse word while speaking with a resident. During interviews, Whinery and S2-S7 did not express concerns regarding inappropriate staff speech. During an interview, R1 was unable to provide details regarding inappropriate staff speech. During interviews, R2-R5 did not express concerns regarding inappropriate staff speech.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 5
Control Number 27-AS-20230523170557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 08/01/2023
NARRATIVE
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Whinery was unable to provide LPA Moleski an incident report regarding an incident alleged by the complainant, during which staff allegedly did not respond timely to a call for assistance. LPA Moleski reviewed daily notes for R1 and did not find any indication that the incident alleged by the complainant occurred. LPA Moleski interviewed R1 and R1 said the incident alleged by the complainant “never happened.”

The department has determined the following as it relates to the allegations that staff speak inappropriately in the presence of residents and that facility staff did not respond to residents call in a timely manner:

Based on interviews with Whinery, S2-S7, and R1-R5, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was left with Whinery.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
05/23/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230523170557

FACILITY NAME:ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITYFACILITY NUMBER:
347005512
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 57DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Morgan WhineryTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff mismanaged residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit.

This investigation consisted of interviews with S1, review of resident records, and review of two incident reports.

LPA Moleski reviewed an incident report dated May 15, 2023. The report described three separate medication issues for three different residents. R1 was stated to have been “taking [the] wrong dose” of a medication. R6 was stated to have received “a change in orders,” but the “medication was D/C [discontinued] when it should have just been changed.”

[Continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 5
Control Number 27-AS-20230523170557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 08/01/2023
NARRATIVE
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A second incident report dated May 3, 2023 provided details regarding R1’s medication error. This incident report stated that R1 had an order to take a prescribed medication with a dose of “5 mg PO [per os] for 5 days skip 2 days,” but the doses being administered were “25 mg PO [per os] for 5 days and skipped 2 days.” The report states that “the resident was taking the wrong dose of 25 mg.” According to the incident report, the error was corrected after being discovered on April 27, 2023.

During an interview, S1 said R1’s family members had brought in a 25 mg bottle of the medication, as R1 had previously been prescribed 25 mg doses. The facility accepted the bottle, but the discrepancy between dosage amounts on the bottle and on the prescription was not noticed by medication technicians prior to administration, according to S1.

LPA Moleski reviewed three doctor’s orders for R6 and medication administration records (MARs) for R6 for the months of February through May 2023. The first order was dated January 19, 2023, and it discontinued a medication in 25 mg tablet form. The second order was dated January 25, 2023, and it ordered R6 to start 25 mg of the same medication in sprinkle form. The third order was dated May 15, 2023, and it discontinued the preceding prescription for that same medication.

During an interview, S1 said the first discontinuation order dated January 19, 2023 was received and transferred correctly into R6’s MARs. The second order, which started the medication in sprinkle form, was not transferred into the MARs, according to S1. R6’s MARs showed R6 did not receive any dosages of this medication between February 13, 2023 and May 9, 2023. The medication was discontinued as of May 16, according to the MARs.

The department has determined the following as it relates to the allegations that facility staff mismanaged residents’ medications:
Based on interviews with S1 and based on review of resident records and incident reports, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87465(a)(4). An exit interview was held with Whinery. Appeal rights and a copy of this report was left with Whinery.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230523170557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87465(a)(4)
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22 CCR Section 87465(a)(4) - Incidental Medical and Dental Care: "(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(4) The licensee shall assist residents with self-administered medications as needed."
This requirement was not met as evidenced by:
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Licensee previously conducted staff training regarding medication administration. Licensee agrees to send LPA Moleski training records.
vincent.moleski@dss.ca.gov
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Based on interviews and review of incident reports and resident records, medications were not administered as required by R1's and R6's doctor's orders, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5