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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700250
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:21:38 PM

Unsubstantiated


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
10/22/2021 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211022164239
FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR:PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 298-7258
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:24CENSUS: 22DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Priscilla QuitevisTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Residents are not being changed
Residents are not being fed in a timely manner
INVESTIGATION FINDINGS:
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On 11/5/21 at 9:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegations listed above. LPA met with Administrator Priscilla Quitevis and explained the purpose of the visit. Throughout the course of this investigation, LPA interviewed Staff1 (S1) on 10-26-21, and S2, S3 and S4 on 11-5-21. LPA also observed Resident1 (R1) on 10-26-21 and interviewed R2, R3, and R4 on 11-5-21. LPA also reviewed facility file documentation including needs and service plan for R1, medication orders for R1, care notes, menu, staffing roster, staffing schedule, physician’s report for R1, and resident roster. Based on observation and care logs reviewed, it was determined that staff attempted and completed necessary care for R1 including turning, changing, and feeding assistance. Based on resident interviews, it was determined that a lack of necessary care, timely care, and timely meal delivery was not observed or expressed. An interview with hospice on 10-28-21 determined that a hospice care plan was in place for R1.

{Cont. on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 5
Control Number 27-AS-20211022164239
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: OPTIMUM SENIOR CARE HOME
FACILITY NUMBER: 392700250
VISIT DATE: 11/05/2021
NARRATIVE
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LPA observed and reviewed hospice care plan on 11-5-21 and it was determined that a plan for assistance with activities of daily living was in place in addition to infection control and swallowing precautions.

Based on interviews, observation, and record reviews it is determined that the preponderance of evidence standard is not met and therefore, the above allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/22/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211022164239

FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR:PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 298-7258
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:24CENSUS: 22DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Priscilla QuitevisTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Residents are not being provided medications as ordered
INVESTIGATION FINDINGS:
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On 11/5/21 at 9:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegation listed above. LPA met with Administrator Priscilla Quitevis and explained the purpose of the visit. Throughout the course of this investigation, LPA interviewed Staff1 (S1) on 10-26-21, and S2, S3, and S4 on 11-5-21. LPA also observed Resident1 (R1) on 10-26-21. LPA also reviewed medication orders and medication log sheets for R1. On 10-26-21, LPA observed a nutritional supplement supplement, and it was determined based on interview with S1 that nutrition supplement belonged to R1. Based on interview with S1 it was revealed that nutrition supplement arrived at facility on 10-23-21 and available for R1. Based on review of medication orders, a physician’s order was in place for nutrition supplement on 10-8-21 and again on 10-19-21. Based on additional interview with S1, it was revealed that nutrition supplement was not available until 10-23-21 due to R1’s insurance.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211022164239
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: OPTIMUM SENIOR CARE HOME
FACILITY NUMBER: 392700250
VISIT DATE: 11/05/2021
NARRATIVE
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A review of medication log sheets reveals nutrition supplement was not started until 10-23-21 at 5:00pm.

Based on interviews and record reviews, it is determined that the nutrition supplement was not given as ordered to R1 and the preponderance of evidence standard is met, therefore, this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22, Division 8 and noted on LIC 9099D.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211022164239
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: OPTIMUM SENIOR CARE HOME
FACILITY NUMBER: 392700250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
87465(a)(5)
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87465 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... (5) The licensee shall assist residents with self administered medications as needed.
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Licensee will develop a written plan to ensure medications are given to residents as ordered. Licensee to submit plan to LPA by POC due date.

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This requirement is not met as evidenced by: Based on interview and record reviews, Licensee did not ensure the timely delivery of a nutritional supplement for R1 as ordered by Physician on 10-8-21 and 10-19-21. Nutritional supplement was given to R1 on 10-23-21. This poses a potential health and safety risk to residents in care.
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Licensee will conduct staff training on assisting with self-administered medications with ephasis on acknowleging physician orders. Licensee to submit proof of training completed to LPA by POC due date.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5