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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701033
Report Date: 02/03/2023
Date Signed: 02/05/2023 06:09:48 PM

Substantiated


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
11/29/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221129095312
FACILITY NAME:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Olivia KellyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not properly supervise residents
Staff did not distribute resident's medication as prescribed
INVESTIGATION FINDINGS:
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LPA Johnson arrived at the care facility and met with Staff to deliver findings for the above allegations.

Allegation: Staff do not properly supervise residents.

Based on records reviewed the facility did not properly supervise R1 and as a result R1 was AWOL from the facility on 11/22/2022. The facility did not report this incident to the department, the facility contacted the Stockton Police Department and a silver alert was sent out by the California Highway Patrol. R1 was unaccounted for approximately from 9pm on 11/22/22 and 5am 11/23/22. The Stockton Police department released an update on 11/23/22, stating that R1 was found no time was given.
Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 6
Control Number 27-AS-20221129095312
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: ST. RITA CARE HOME
FACILITY NUMBER: 392701033
VISIT DATE: 02/03/2023
NARRATIVE
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Allegation: Staff did not distribute resident's medication as prescribed

Based on medication administration records the facility did not provided R2 with medication that was prescribed. The facility stated that the Hospice agency was made aware of the fact that R2 was out of medications. The facility has no documentation to support that they informed the hospice agency about the missing medication for R2. The medication were out for two days. The facility did not have a PRN letter for R3 to take a controlled medication for pain. The facility also failed to assist R3 with insulin as prescribed by R3's physician. The facility did not report this medication error to the department


The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20221129095312
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: ST. RITA CARE HOME
FACILITY NUMBER: 392701033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
87705(j)
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Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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Licensee shall provide a training plan for staff on dementia and activities. POC due by POC due date. 2/4/2023
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This requirement is not met as evidenced by: CCL received a notice that R1 was featured on the local news as a silver alert /missing from facility. Based on confirmation of the Administrator the staff did not notice R1 Awol’d from the facility. Calls were made to the police department, they later found R1
This poses an immediate health and safety risk to residents in care.
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Type A
02/04/2023
Section Cited
CCR
87465(a)(4)
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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, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.
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Licensee will submit a plan to ensure residents are receiving medications as ordered. Plan to be submitted to LPA by POC due date
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This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure R2 receive prescribed medications for a period of more than 2 days and failed to assist R3 with insulin as prescribed. This poses an immediate health and safety risk to residents in care.
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Licensee will ensure staff training on medication regarding physician’s orders and working with pharmacies is completed. Proof of training to be sent to LPA by POC due date
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
11/29/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20221129095312

FACILITY NAME:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 5DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Olivia KellyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not manage resident's behavior
Staff did not assist resident with incontinence care
Resident sustained injury while in care
Staff did not assist resident with ambulating
Staff did not meet resident's dietary needs
Staff did not assist resident with showering
Staff did not provide resident with privacy during visiting
Staff interfered with resident's phone calls
Staff did not allow resident to choose care provider
INVESTIGATION FINDINGS:
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Allegation: Staff do not manage resident's behavior, Based on records reviewed the facility has a plan in place for R4's behaviors, the facility uses placement strategies to keep R4 from assaulting others. R4 speaks Spanish and at times will attempt to get close to others to communicate or show others what she is trying to convey. LPA was unable to establish a time or day when R4 assaulted any residents.

Allegation: Staff did not assist resident with incontinence care, Based on records reviewed the facility has an ADL/log chart that details when residents are changed, feed and checked on daily. LPA reviewed these documents and based on the infromation reviewed was unable to determine a day when residents were not attended to with incontinence care.

Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 6
Control Number 27-AS-20221129095312
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: ST. RITA CARE HOME
FACILITY NUMBER: 392701033
VISIT DATE: 02/03/2023
NARRATIVE
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Allegation: Resident sustained injury while in care, based on records reviewed and interviews conducted the facility did not have an incident report or anything noted in the communication log regarding ER visits, changes in condition or any situation that may have confirmed that a resident sustained an injury while in care at this facility. LPA was unable to determine a day when a resident was sent out for an injury while in care at this facility.

Allegation: Staff did not assist resident with ambulating, Based on records and interviews with the facility the residents in care have charting check list or documentation that supports attempted / assisted care with ADLs, Based on service needs the facility provides care with ADL and if noted assistance with ambulation. LPA was unable to determine a date or time when a resident was not assisted with ADLs.

Allegation: Staff did not meet resident's dietary needs, the facility provided the department with a copy of their menu for three months and the department inspected the food at the facility and noted that the seven day non-perishable and two day perishable food supplies was in place. The department was unable to determine if on a specific date the facility did not meet the dietary need of any resident in care.

Allegation: Staff did not assist resident with showering, Based on records reviewed the facility makes attempts and documents those attempt to provide the residents with ADLS. The facility has documentation of attempts to provide multiple residents with assistance including showers. The facility has successes and attempts to provide these services. There is not a specific day when the facility failed to make an attempt or assist residents. LPA was unable to determine a date or time when a resident was not assisted with ADLs.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20221129095312
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: ST. RITA CARE HOME
FACILITY NUMBER: 392701033
VISIT DATE: 02/03/2023
NARRATIVE
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Allegation: Staff did not provide resident with privacy during visiting, Based on interviews and observation the facility provides the residents with shared rooms, common areas and outdoors seating. The residents have the ability to move to these areas or request to have assistance to move to these areas. The residents can use these areas for visiting or make a request to use these areas for privacy. The facility denies not having private areas for the residents to meet with families. The department was unable to determine if staff or the facility refused any residents from going to private areas for visit with their families or any other persons.

Allegation: Staff interfered with resident's phone calls, Based on observation and calls the facility has a land- line the residents are allowed to use this land- line number (209) 451-1634. Staff interviewed recalled a day when a residents was using the phone and that resident was using the phone on the speaker feature, Staff informed the resident that the other could hear the conversation and ask that resident to take the phone off speaker. This was done to maintain the privacy of the conversation that was taking place. The facility denied at anytime interrupting residents conversation or listening in on the conversations of any residents in care.

Allegation: Staff did not allow resident to choose care provider, based on interviews and records reviewed the facility uses FOBI Comprehensive Pharmacy as there preferred source for medication services. The facility does not have a requirement that all residents use this pharmacy. There is no service agreement or form that needs to be signed by the Residents or the responsible party. The facility stated that this information is shared with the residents and/or the responsible party at time of admission.

Based on interviews, observations, and record reviews it is determined that there is not a preponderance of evidence to prove that Staff pinched resident. Additionally, there is not a preponderance of evidence to prove Resident sustained injury while in care. As a result, the above allegations are UNSUBSTANTIATED.

An exit interview was conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6