347005677-1-4-2021-27-AS-KLEL-BWXV95-20210104151345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005677
Report Date: 01/04/2021
Date Signed: 01/04/2021 03:14:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LOVE AND DIVINE HOME CARE		FACILITY NUMBER:	347005677
ADMINISTRATOR:	IVANCICH, LARRY		FACILITY TYPE:	740
ADDRESS:	303 OAK CANYON WAY		TELEPHONE:	(916) 932-4883
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	6	CENSUS: 4	DATE:	01/04/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Larry Ivancich (Administrator)		TIME COMPLETED:	02:15 PM

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	An office meeting was held on January 4, 2021 to follow up on a substantiated allegation of neglect/lack of supervision. Present at the conference were Laura Munoz, Acting Regional Manager; Troy Ordonez, Licensing Program Manager; Rayna Bryson Licensing Program Manager; Konnor Leitzell, Licensing Program Analyst; and the licensee Abundant Living Home Care LLC, Love and Divine Home Care (Larry Ivancich, Tyler Ivancich, and Lisa Ivancich) On November 7, 2019, the Department conducted a complaint investigation which alleged the following: Medical treatment was not provided to resident in a timely manner resulting in injury and hospitalization. The licensee was cited for violating California Code of Regulation (CCR) Title 22, § 87465 (g) Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. The licensee was also cited for violating Title 22, California Health and Safety Code (H&S) 1569.312(e) which states “Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being”. On September 16, 2019, the facility failed to meet the needs of Resident 1 (R1), who suffered unwitnessed fall and was left in pain for over nine hours before being admitted to the hospital with a diagnosis of a left hip fracture. Medical evaluation report (LIC 602) diagnosed R1 with dementia. The report documented that R1 was unable to leave the facility unassisted and had a wandering behavior dated January 4, 2019. Cont. LIC809c

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: LOVE AND DIVINE HOME CARE	FACILITY NUMBER: 347005677
	VISIT DATE: 01/04/2021

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

Based on staff interviews and facility records, it was revealed R1 had a history of wandering. According to case notes obtained from the facility it was noted that R1 was a wanderer and had been exit seeking on the previous dates of September 2, 2019, September 7, 2019, and September 14, 2019. It was also noted per the case notes that R1 would wander into other residents’ rooms, during the day and night. R1 had an unsteady gait and would cross their legs while walking. R1 had a walker to assist with ambulation but interview indicated R1 did not like using the walker. On September 16, 2019, R1 was awake and wandering the facility around 5:00 a.m. Two staff were present at the facility during this time. According to an interview with Staff 1 (S1), one staff was in the staff room and the other staff had gone to the restroom. S1 indicated when R1 was checked on (staff could not state exact time), R1 was sleeping on a recliner in the living room. Interviews reveled R1 was found on the floor in another resident’s bedroom around 5:30 a.m.

When staff found R1, interviews indicated R1 refused staff to be picked up. Interviews indicated R1 was non-verbal. S1 stated R1 was too heavy for them to pick up so S1 called the assistant administrator to assist in picking up R1 off the floor. S1 stated R1 was mumbling something but S1 still could not understand R1.

S1 stated she and S2 picked R1 up off the floor before the assistant administrator arrived at the facility and put R1 in the wheelchair and moved R1 to the living room. The assistant administrator arrived at the facility between 6:30 a.m. and 7:00 a.m.

Interviews indicated around 10:00 a.m. staff noticed R1 was wincing when moving the left leg during a shower. Facility staff contacted R1’s responsible party around 12:08 p.m. R1’s responsible party arrived at the facility around 3:00 p.m. R1 was sitting in the wheelchair on the right side because R1 could not sit on the left side. R1 was transferred to a private car and taken to the Emergency Room (ER) by R1’s responsible party. According to R1’s medical records, Emergency room notes documented R1 could not bear weight. R1 was diagnosed with a left hip fracture. According to the Mayo Clinic, “a fractured hip signs and symptoms include the inability to get up from a fall or to walk, severe pain in your hip or groin, inability to put weight on your leg on the side of your injured hip, bruising and swelling in and around your hip area, shorter leg on the side of your injured hip and outward turning of your leg on the side of your injured hip.”

CONT. LIC809C

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: LOVE AND DIVINE HOME CARE	FACILITY NUMBER: 347005677
	VISIT DATE: 01/04/2021

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

The facility submitted an incident report to the Department on September 19, 2019. Incident report indicated R1 was observed wandering the halls by the night staff between 5:00 a.m. and 5:30 a.m. The Incident report stated the R1’s family knew R1 needed a walker, however the resident refused to use it. R1’s family has been notified during the past year that R1 was a fall risk. The incident report goes on to state that during the day the staff strictly observe R1’s every movement all around the house.

According to care notes from the facility dated September 09, 2019 to September 16, 2019, R1 wanders the facility aimlessly. Interviews with staff stated R1 bumps into walls, counters and other objects as R1 has an unstable gait and is supposed to use a walker to assist in ambulation.

Based on interviews and documentation, the licensee failed to seek timely medical attention for R1 when the facility observed R1 wincing in pain after an unwitnessed fall which resulted in a left hip fracture. R1 fell at around 5:00 a.m. and did not receive medical attention until after 3:00 p.m.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, January 4, 2021 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. LPA provided facility with a copy of the report via email with read receipt to acknowledges facility receiving the documents. LPA requested administrator to review, print and sign one copy of the report and return it by COB 1/5/2020. LPA requested administrator to keep one copy of report for facility file. Appeal Rights provided, which are found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3