392700475-1-19-2024-27-AS-MJEN-CZMVLL-20240119153205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:32:13 PM

Document Has Been Signed on 01/19/2024 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	OAKS AT INGLEWOOD ASSISTED LIVING, THE		FACILITY NUMBER:	392700475
ADMINISTRATOR:	BRITTANY ANDREWS		FACILITY TYPE:	740
ADDRESS:	6725 INGLEWOOD AVE		TELEPHONE:	(209) 957-6257
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	86	CENSUS: 77	DATE:	01/19/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Tha Chay		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Maja Jensen arrived on 1/19/24 for an unannounced case management to follow up on an incident report made by the facility. LPA Jensen met with Tha Chay and explained the purpose of today’s visit. Per facility’s Unusual Incident/Injury Report, on 04/20/2020, at approximately 7:30 am, facility staff answered Resident 1’s (R1’s) call. R1 reported she fell and hit her head. 911 was called.

The Department conducted an investigation which consisted of a review of medical records and facility records. Records indicate that R1 was admitted to the facility on March 6, 2020.

Facility notes document the following occurrences:

-R1 had an appointment scheduled to remove a stent but this was postponed until May of 2020.

-On 3/11/2020, R1 complained of pain in her back and no medical attention was sought.

-On 3/14/2020, R1 complained of stomach pain and no medical attention was sought.

-On 4/3/2020, R1 complained of stomach pain and no medical attention was sought.

-On 4/4/2020, R1’s daughter was called. R1’s daughter stated she was aware of the stomach pains due to kidney stones. Staff suggested to increase fluids.

-On 4/15/2020, R1 complained of stomach pain and no medical attention was sought.

-On 4/16/2020 at 12pm and 6pm R1 complained of stomach pain and no medical attention was sought.

-On 4/18/2020 Staff called daughter of R1 and informed her of the constant stomach pain. R1’s daughter stated she will try to schedule an appointment for Monday (4/20/2020).

-On 4/20/20 R1 was admitted to the hospital with an admission diagnosis of severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis.

Continued on LIC 809C....

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE	FACILITY NUMBER: 392700475
	VISIT DATE: 01/19/2024

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On 04/22/2020 10:30 pm R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death.

Based on the review of the medical records, and other miscellaneous documents, the facility delayed medical assistance and that resulted in a hospitalization leading to death from septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst. In addition, the facility did not recognize R1’s change in condition.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. The Department is also reviewing additional civil penalties which may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted. A copy of this report, appeal rights and a confidential names list (LIC 811) was given to Tha Chay.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2024 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE	FACILITY NUMBER: 392700475
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/20/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	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...	1 2 3 4 5 6 7	The Licensee or Administrator agrees to email facility policies for calling 9-1-1 and changes in condition to maja.jensen@dss.ca.gov within 24 hours. The Administrator further agrees to conduct in-service training on 1-25-24.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the facility notes and medical records which show medical assistance as delayed to R1. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type A 01/20/2024 Section Cited CCR87466	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed for changes ...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician....This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee or Administrator agrees to email facility policies for calling 9-1-1 and changes in condition to maja.jensen@dss.ca.gov within 24 hours. The Administrator further agrees to conduct in-service training on 1-25-24.
	8 9 10 11 12 13 14	A review of medical records and facility notes showing R1's complaints of pain were not brought to the attention of R1's physician or responsible party on multiple occasions. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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