392700640-4-3-2024-27-AS-KHOS-D47NYX-20240410105328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700640
Report Date: 03/28/2024
Date Signed: 04/03/2024 09:25:05 AM

Unsubstantiated

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
02/27/2024 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240227125752

FACILITY NAME:	COURTYARD AT RIO LAS PALMAS, THE		FACILITY NUMBER:	392700640
ADMINISTRATOR:	GUERRERO, LIZETH		FACILITY TYPE:	740
ADDRESS:	877 EAST MARCH LANE		TELEPHONE:	(209) 957-4711
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	80	CENSUS: 60	DATE:	03/28/2024
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Lizeth Guerrero		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not follow the needs and services plan.

INVESTIGATION FINDINGS:

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On 04/02/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua met with Facility Designated Administrator (FDA), Lizeth Guerrero and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 60. A brief interview with FDA Guerrero was conducted.

It was alleged that the facility staff did not follow the needs and services plan. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted it was learned that R1 and their responsible party moved into this facility in September 2023. Throughout the months, it was found that R1 needed a higher level of care due to their ambulatory status, frequent hospitalization, and increased services need for their health and safety.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240227125752

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: COURTYARD AT RIO LAS PALMAS, THE	FACILITY NUMBER: 392700640
	VISIT DATE: 03/28/2024

NARRATIVE

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It was stated by facility staff that they attempted to work with R1’s responsible party to obtain additional services from outside sources such as home health and hospice but ultimately was denied by the responsible party. Based on records review, the facility conduct an initial Needs and Services plan based on assessment conducted prior to moving to the facility. The facility conducted a 30-day Needs and Services plan to reflect the current needs for the resident. A 3^rd Needs and Services plan was developed to reflect the current needs of the resident after they came back from the Skilled Nursing Facility. It was learned that the physician recommended that R1 consider going into a Long-Term Care facility. Multiple attempts were made with the facility and the responsible party to get a higher level of care but did not successfully obtain any services due to R1 and their responsible party moving. Based on the information gathered during the course of this investigation, it is unclear whether the facility staff did not follow the needs and services plan.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC9099 (FAS) - (06/04)

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