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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005733
Report Date: 02/19/2021
Date Signed: 02/19/2021 06:15:26 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
05/06/2020 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20200506125824
FACILITY NAME:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:ENERO,EDGARFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
02/19/2021
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Hazel Napalan FloresTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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On 5/7/2020, Licensing Program Analyst (LPA) Victoria Brown conducted an initial 10-day visit. LPA contacted the facility via telephone to commence an unannounced Tele- visit on 2/19/2021 at 4:45pm due to COVID-19 and pre-cautionary measures. LPA met with Administrator Hazel Napalan Flores and discussed the purpose of the call and the elements of this type of visit.
LPA requested, received and reviewed a copy of the incident report submitted to Community Care Licensing on 1/15/2020 regarding resident #1 (R1)'s incident of a fall that occurred on 1/8/2020. LPA also requested, received and reviewed a copy of following for R1: Admission Agreement, Physician Report, Daily Report Sheet, ID and Emergency Information, Centrally Stored Medication Log, MARs, Appraisal and Needs Service Plan, Assessments, and Hospice records. In reviewing the admission agreement, LPA observed that R1 was admitted to the facility on 5/16/2019.

Regarding allegation, “Resident sustained a fracture while in care” LPA observed the Preplacement Appraisal Information (LIC603) dated 5/13/2019 which indicate under Functional Capabilities regarding the use of a walker the boxes yes and no were marked. LPA received a (LIC624) Unusual Incident Report indicating that R1 had a fall on 1/8/2020 while attempting to get a snack from a cabinet.
Substantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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 7
Control Number 27-AS-20200506125824
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2021
Section Cited
CCR
87465g
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Incidental Medical and Dental Care Services
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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Administrator shall submit a plan on how the facility will secure supervision of the residents which shall be faxed by POC due date. 2/20/21.
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This requirement is not met as evidenced by: Facility did not call 911 after R1 had a fall until the next day when R1 mentioned pain on both days.
Based on a review of documentation and interviews the facility staff did not seek medical attention in a timely manner. This poses an immediate health and safety risk to residents in care.
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You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client.
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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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200506125824
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
VISIT DATE: 02/19/2021
NARRATIVE
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On 1/8/2020, LPA did not observe that 911 was initiated and that R1 refused medical attention. However, on 1/9/2020 R1 complained of right hip pain and was transported to seek medical attention. LPA observed a handwritten Daily Report Sheet for the date of 1/8/2020 by staff. The Daily Report Sheet indicated that R1 had a fall, no bruises and complained of right-side hip pain at which time staff administered a Pro re nata (PRN) meaning when required Tylenol 325mg and provided a hot compress for R1’s hip. During an interview with S1 on 5/7/2020, revealed that R1 fell and yelled at staff to not call 911 and asked for Tylenol. Staff applied an ice pack to the hip and EMS was contacted the next morning to make sure R1 was ok. R1 went to hospital then rehabilitation and released 3 weeks later. When R1 returned the staff found out there was a fracture and R1 came with physical therapy and occupational therapy.
During an interview with S2 on 5/7/2020, revealed that R1 fell when S2’s shift was ending. S2 went to see R1 who was found on the floor. R1 spoke of pain and Tylenol was administered by staff and the physician was notified.

Based on interviews, the licensee failed to obtain timely medical attention when the resident had a fall and suffered serious bodily injury to include being diagnosed with a fracture, upon admission to the hospital. The licensee’s failure to seek timely emergent care caused the resident to suffer serious bodily injury.

The preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining a fracture (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted with Hazel Napalan Flores via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/06/2020 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20200506125824

FACILITY NAME:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:ENERO,EDGARFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
02/19/2021
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Hazel Napalan FloresTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care.
Staff did not provide food in the quantity necessary to meet resident's needs.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele- visit via Microsoft Teams on 2/19/2021 at 2:30pm due to COVID-19 and pre-cautionary measures. LPA met with Administrator Hazel Napalan Flores and discussed the purpose of the call and the elements of this type of visit.

Regarding allegation, “Resident sustained multiple pressure injuries while in care”, during an interview with the Administrator on 5/7/2020, she stated that R1 did not have pressure injuries at all and that there was a prescription for Triamcinolone 0.1% for Eczema.
During an interview with S1 on 5/7/2020, it was revealed that all staff used Jergens lotion on the resident’s skin along with the prescribed medication Triamcinolone 0.1% twice a day on R1 for itching. S1 also stated that R1 did not have bedsores.
On 5/7/2020, LPA interviewed S2, it was revealed that R1 did not have bedsores but had redness from scratching a lot from having very dry skin. For about 7 months the staff used a lot of lotion on R1.
LPA did not observe any documents to substantiate R1 had pressure injuries while in the facility. UNSUBSTANTIATED
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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 7
Control Number 27-AS-20200506125824
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
VISIT DATE: 02/19/2021
NARRATIVE
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Regarding allegation, “Staff did not provide food in the quantity necessary to meet resident's needs” On 5/7/2020, LPA observed 3 residents having lunch which consisted of Chow Mein, chopped Chicken and lemon Cake for dessert. LPA observed R1 inquiring about the menu for lunch, saying, “Okay I’ll eat that”. LPA observed R1 eating by self and initially refusing assistance from staff. R1 accepted encouragement from staff at the end of the meal. R1 also requested warm water to drink.
LPA observed R1 eating 1 small piece of the chicken breast by self and 2 forks of Chow Mein with staff assistance. Staff then coached R1 to eat 1 more bite at which time R1 said no and picked up the fork and ate 1 more bite by self. R1 then drank a cup of tea and a cup of hot water telling staff “no more”. R1 then drank the Ensure that was offered and 1 fork of lemon cake with a reminder to chew and swallow. Afterwards, R1 requested cold water. LPA observed the Preplacement Appraisal Information LIC603 dated 5/13/2019 which indicates R1 can feed self sometimes. LPA observed on the LIC602 dated 5/18/2019 indicates R1 can feed self.
LPA observed on the following dates of 2020 that R1 was able to communicate not hungry and opted to skip a meal: 2/6 ,2/17, and 4/22.
On the following dates R1 opted to skip a meal and requested a snack on 2/20/20, and 3/23/20. The Daily Report Sheet indicated on these dates R1 did not eat much 4/19/20, 4/23/20, 4/24/20 and family was notified on 4/25/20, 4/26/20, 4/27/20,4/28/20, 4/29/20, 5/1/20, 5/4/20, 5/5/20 at which time R1 would only eat 2-3 bites of food but would drink the ensure. On 5/6 R1 ate 30% of food and drank the ensure. On 5/2/20, R1 began medication to improve appetite at which time staff began spoon feeding R1 to assist.
During an interview with the Administrator on 5/7/2020, she stated that R1 was initially eating by self but began to decline and only eat a tiny bit. She stated that all the residents receive the same portion of food. The responsible party was notified and would supply Ensure for R1. The Physician supplied a prescription to assist in increasing R1s appetite.
During an interview with S1 on 5/7/2020, it was revealed that R1 was prescribed a medication to increase the appetite. The physician was informed of the lack of appetite except for sweets, pain, and weakness. S1 stated R1s bowel function was working fine.
During an interview with S2 on 5/7/2020, it was revealed that R1 could only eat very small amounts but even less later. S2 stated that R1 did not complain about the food except to say that it’s too much. R1 likes pastries and cakes but did not like fruits.

As a result of the investigation of this allegation, the preponderance of evidence has not been met. Therefore, the allegation is deemed to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/06/2020 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20200506125824

FACILITY NAME:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:ENERO,EDGARFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
02/19/2021
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Hazel Napalan FloresTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not assist resident with medications as needed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele- visit via Microsoft Teams on 2/19/2021 at 2:30pm due to COVID-19 and pre-cautionary measures. LPA met with Administrator Hazel Napalan Flores and discussed the purpose of the call and the elements of this type of visit.

Regarding allegation, “Staff did not assist resident with medications as needed”, LPA observed the Preplacement Appraisal Information LIC603 dated 5/13/2019 that has conflicting information for R1. It indicates R1 needs help with medications and that R1 can take medications by self. LPA observed the (LIC602) Physician Report dated 5/18/2019 which indicates R1 is not able to administer nor store medications. During an interview with S1 on 5/7/2020, it was revealed that R1 was prescribed a medication to increase the appetite and when it was almost depleted, S1 called to have it refilled.
During an interview with S2 on 5/7/2020, it was revealed that staff had a problem with this particular physician regarding medication refills for all of their residents. The Ensure drink was provided to R1 until a call back was received from that physician.
Unfounded
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200506125824
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
VISIT DATE: 02/19/2021
NARRATIVE
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LPA obtained information that the physician prescribed a medication to increase the appetite of R1 which needed to be refilled, however, the doctor had not responded to the facility nor the pharmacy. The Administrator asked the responsible party to provide Centrum Silver vitamins until the appetite prescription was filled. However, both prescriptions were filled by the pharmacy. According to the Administrator the vitamins were never administered because the appetite medication was filled.

LPA observed the Medication Assistance Record dated 7/2020 which noted that the Registered Nurse from Home Health administered Morphine (5mg every 2 hours) Pro re nata (PRN) which means when needed while R1 was on hospice living at a different facility.

The investigation revealed that R1 was not receiving hospice care services or morphine while residing at this facility. The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. An exit interview was conducted with via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

"This agency has investigated the complaint alleging the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7