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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004012
Report Date: 08/23/2021
Date Signed: 08/23/2021 02:44:41 PM

Document Has Been Signed on 08/23/2021 02:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
08/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Julia Fragoso, Facility ManagerTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Bruce Jacobs conducted a case management visit at the facility to issue deficiencies relating to an incident report not submitted to the Department. LPA met with Facility Manager Julia Fragoso and the purpose of the visit was disclosed. On August 12, 2021, Licensing Program manager Liza King conducted a phone call the Administrator. During that phone call, information was obtained that the facility had a resident (R-1) who had tested positive for an infectious disease while hospitalized. Upon further review, the facility did not submit an incident report as required. In addition, it was determined that the facility did not conduct the required testing of staff of staff per Provider Information Notice (PIN) 21.32 or PIN 21.32.1 for surveillance testing or response testing after received a positive test result, per standard guidance as well.

Case management deficiencies are being issued on the following 809Ds. Appeal rights provided and exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/23/2021 02:44 PM - It Cannot Be Edited


Created By: Bruce Jacobs On 08/23/2021 at 06:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RIVER FOUNTAINS OF LODI
FACILITY NUMBER: 397004012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/31/2021
Section Cited
HSC
1569

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Conduct Inimical: Conduct which is inimical to the health, morals, welfare, or safety of either an individual in, or receiving services from, the facility or the people of the State of California.
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Plan of Correction: The Facility Administrator will review the PINs that provides instructions for staff testing. Facility will submit a statement to the Department by 8/31/21 that the PINs have been reviewed, understood and are being followed
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This requirement was not met as evidenced by: Facility did not follow the Department's guidance of conducting surveillance testing of unvaccinated staff once per week per Provider Information Notice (PIN) 21.32 and later PIN 21.32.1 This poses an immediate health and safety risks to clients in care.
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Type B
08/31/2021
Section Cited
CCR87211(a)(1)(B)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision 87211(a)(2) Occurrences, such as epidemic outbreaks,
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Plan of Correction: The Facility Administrator will review the corresponding regulation on reporting requirements. Facility will submit a statement to the Department by the POC due date that this regulation has been reviewed, understood and is being followed
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This requirement was not met as evidenced by: A resident of the facility was hospitalized and determined to have an infectious disease on 7/26/21. The facility failed to submit an incident as required to the department. This poses a potential Health and Safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 08/23/2021 02:44 PM - It Cannot Be Edited


Created By: Bruce Jacobs On 08/23/2021 at 06:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RIVER FOUNTAINS OF LODI
FACILITY NUMBER: 397004012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87405(d)(2)

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Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. this requirement was not met as evidenced by:
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Plan of Correction: The Facility Administrator will review this regulation and the corresponding PINs that provides instructions for staff testing. Facility will submit a statement to the Department by 8/31/21 that both this regulation the PINs have been reviewed, understood and are being followed.
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Facility Administrator did not follow the reporting requirements or the staff testing requirements of PIN # .21.32 and 21.32.1. The Facility Administrator is responsible for knowledge of CCR regulations and compliance of the regulations. This poses a potential Health and Safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
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