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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004012
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:09:28 AM



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
01/20/2021 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210120095513
FACILITY NAME:RIVER FOUNTAINS OF LODIFACILITY NUMBER:
397004012
ADMINISTRATOR:REBECCA COBBFACILITY TYPE:
740
ADDRESS:311 WEST TURNER ROADTELEPHONE:
(209) 334-3763
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:80CENSUS: 54DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Rebecca CobbTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision:
1) Resident sustained serious injuries due to a fall
2) Staff did not notify residents authorized representative of residents change in condition
3) Staff did not check on resident in a timely manner
Physical Plant:
1) Residents bathroom light is in disrepair
2) Residents bedroom was filthy
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to River Fountains of Lodi RCFE on 07/12/21 at 10:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. Interviews with hospital staff were unable to determine if R1s fall contributed to her condition or death. Investigator could not determine if R1 was at risk for falls or if the facility staff were negligent in caring for R1. Investigator also could not determine if R1 had a change in conditional that was not reported by facility staff. Investigator received conflicting statements from parties interviewed and could not make a determination.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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 4
Control Number 27-AS-20210120095513
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: RIVER FOUNTAINS OF LODI
FACILITY NUMBER: 397004012
VISIT DATE: 07/12/2021
NARRATIVE
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LPA Gould conducted interviews with staff member who responded to request for assistance fro R1. LPA received contestant statements from staff that responded once request was received and calls were made to staff to assist R1 in her room. Several staff responded and assisted R1. LPA Gould also could not evaluate the physical plant complaints regarding R1's bedroom and bathroom. When LPA inspected the physical plant all personal items had been removed and the room had been cleaned. LPA also observed the bathroom light to be operational at the time of inspection.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision and physical plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
01/20/2021 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210120095513

FACILITY NAME:RIVER FOUNTAINS OF LODIFACILITY NUMBER:
397004012
ADMINISTRATOR:REBECCA COBBFACILITY TYPE:
740
ADDRESS:311 WEST TURNER ROADTELEPHONE:
(209) 334-3763
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:80CENSUS: 54DATE:
07/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Rebecca CobbTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision: Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to River Fountains of Lodi RCFE on 7/12/21 at 10:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because R1 (see confidential name list LIC-811 dated 7/12/21) was sent to the hospital following staff observing blood in urine for R1 the morning after sustaining an unwitnessed fall. On the date of the fall, all paries interviewed provided consistent statements that R1 refused to go to the hospital the night of the fall and had no complaints of pain following the fall.

The Department has investigated the complaint alleging Neglect/Lack of Supervision. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210120095513
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: RIVER FOUNTAINS OF LODI
FACILITY NUMBER: 397004012
VISIT DATE: 07/12/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4