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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:52:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20221227132746
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: 56DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Morgan GreenwoodTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not provide resident medication as needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Executive Director Morgan Greenwood.

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

The Department has determined the following as it relates to the allegations: Staff do not provide resident medication as needed.

Continued on LIC 9099 - C...


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20221227132746

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: 56DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Morgan GreenwoodTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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9
Staff leave resident in bed for an extended period of time.
Staff leave resident soiled for an extended period of time.
Staff are not providing adequate meal services to resident.
Staff are not meeting resident's showering needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Executive Director Morgan Greenwood.

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

The Department has determined the following as it relates to the allegations: Staff do not provide resident medication as needed.

Continued on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20221227132746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY
FACILITY NUMBER: 347005512
VISIT DATE: 10/10/2023
NARRATIVE
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On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness R1 was in the bed upon each visit to R1. However, according to witness statements, witness visited R1 in the late and early hours of the night. According document review, on page 5 of 6 on LIC602A dated 8/23/2022 R1 is listed as non-ambulatory. According to staff interviews, facility record files and resident interviews, residents are not left in bed for an extended period of time. Therefore in regard to the allegation Staff leave resident in bed for an extended period of time, the allegation is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 9/15/2023 LPA reviewed resident file documents for R1 received from facility on 4/18/2023. On 9/15/2023 LPA conducted staff and resident interviews regarding current allegations. On 10/10/2023 LPA conducted a tour of the facility and observed current residents to be clean. According to interviews with staff and residents there has been no residents that have been soiled for long periods of time. Based on interviews with staff, residents are checked every two hours to ensure they not soiled. On 9/15/2023 LPA received facility chart notes and files that have annotated times residents have been changed while soiled. Therefore in regard to the allegation Staff leave resident soiled for an extended period of time the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 9/15/2023 LPA reviewed resident files regarding services provided to R1. On page 3 of 6 of LIC602A letter E, Special Diet for R1 is filled and listed as "Puree Texture/CCHO Diet". On 9/15/2023 witness provided LPA with photographs of R1 meals and they are of puree texture. In accordance with R1s diet restrictions, facility did provide meal services to resident as prescribed. Therefore, the allegation Staff are not providing adequate meal services to resident is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Cont on 9099-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20221227132746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY
FACILITY NUMBER: 347005512
VISIT DATE: 10/10/2023
NARRATIVE
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On 9/15/2023 LPA reviewed resident files regarding services provided to R1. Based on facility files and chart files R1 received showering and bathing services at the minimum of 2 to 3 times a week as was in alignment with facility and hospice care services. Based on staff and resident interviews, residents received showering services based on facility agreements and services were logged in facility chart records. On 9/15/2023 LPA interviewed facility residents and staff regarding current allegations. Based on interviews and record review, R1 has been receiving showering by facility staff and hospice staff. Therefore the allegations Staff are not meeting resident’s showering needs is unsubstantiated. . An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Exit interview held with Executive Director Morgan Greenwood and copy of report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20221227132746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY
FACILITY NUMBER: 347005512
VISIT DATE: 10/10/2023
NARRATIVE
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On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness, R1 was not receiving pain medications as prescribed. On 9/15/2023 LPA conducted a review of facility medication logs and chart notes for the period of 9/23/2022 to 12/18/2022. Based on facility record review, facility did not provide medication to R1 as prescribed. Based on LPA observation, facility did not supply all requested documents as requested by LPA on 9/15/2023. On 9/18/2023 LPA received additional medication chart notes and documents and it was learned facility had not properly annotated medication resident had received. Therefore, staff did not annotate resident medication in accordance with Title 22 Regulations. Based on medication file review and review of the undated Sign-Out Medication Release Form received from the facility, records show missing pain medication that R1 did not receive upon out processing. Therefore in regard to the allegation Staff do not provide resident medication as needed, the allegation is Substantiated. Based on LPAs medication file review and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20221227132746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY
FACILITY NUMBER: 347005512
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2023
Section Cited
CCR
87506(d)(H)
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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...(H) Records of current medications as specified in Section 87506(b)(12)...This was not met as evidenced by:
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Licensee states they will ensure the documents from previous years are readily available by providing LPA a photo of where the documents are kepty No Later Than (NLT) 10/11/2023.
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On 9/15/2023 the Department representative LPA visited the facility to investigate complaint allegations. While at the facility LPA requested resident medical documents and files. The Licensee did not ensure staff could provide documents requested by the Department as required by Title 22 Regulations. This poses an immediate Health and Safety risk to residents in care.
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Type A
10/10/2023
Section Cited
CCR
87464(4)
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87464 Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This was not met as evidenced by:
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Licensee states on October 3, 2023 there has been a full med tech retraining regarding ordering medication, transcribing medication as well as proper use of physicain phone calls and reminders. Trainnig provided by disctrict nurse for Pegasis Inc. Training documentation will be provided to LPA NLT 10/11/2023
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Based on facility medical record review and witness statements, Licensee did not ensure R1 recieved medication as prescribed. This poses an immediate Health and Safety risk to persons 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6