397004012-5-23-2024-27-AS-KHOS-D5XLHV-20240605084657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004012
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:31:01 PM

Substantiated

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
05/08/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240508103430

FACILITY NAME:	RIVER FOUNTAINS OF LODI		FACILITY NUMBER:	397004012
ADMINISTRATOR:	REBECCA COBB		FACILITY TYPE:	740
ADDRESS:	311 WEST TURNER ROAD		TELEPHONE:	(209) 334-3763
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	80	CENSUS: 64	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Rebecca Cobb		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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8
9

Staff mismanaged resident medication.

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/23/2024 at 12:50 PM to deliver complaint findings, LPA Martinez met with Rebecca Cobb and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. The investigation revealed resident 1 (R1) was not administered Insulin per medication orders. R1 was not administered insulin on April 11 thru 14, 2024. On April 15, 2024, R1 was sent to the Emergency Room (ER), which R1 was admitted into the hospital. R1 did not return to River Fountains of Lodi. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this 809 report, 809D page, and appeals rights were given to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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 3

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
05/08/2024 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240508103430

FACILITY NAME:	RIVER FOUNTAINS OF LODI		FACILITY NUMBER:	397004012
ADMINISTRATOR:	REBECCA COBB		FACILITY TYPE:	740
ADDRESS:	311 WEST TURNER ROAD		TELEPHONE:	(209) 334-3763
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	80	CENSUS: 64	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Rebecca Cobb		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff refused to provide resident's authorized person a copy of resident records.

INVESTIGATION FINDINGS:

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2
3
4
5
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7
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9
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12
13

On 05/23/2024 at 12:50 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Rebecca Cobb during today’s visit and explained the purpose of today's visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. According to resident 1 (R1) signed admission agreement, R1 does not have an authorized representative. R1 signed the admission agreement during initial move-in. Additionally, per facility emails R1's family member was notified records would be released to them once POA documentation was provided. Once the facility receive the POA Documentation, medical records were prepared to be released to R1's family member. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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 3

Control Number 27-AS-20240508103430

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: RIVER FOUNTAINS OF LODI	FACILITY NUMBER: 397004012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/23/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility has completed an Incidental Medical and Dental trainings for all Med-Techs on 05/17/2024 and 05/23/2024. POC Cleared at visit.
	8 9 10 11 12 13 14	Based on file review and interviews, the Licensee did not ensure R1 was assisted with administering Insulin as prescribed by their physician. This posed a potential health and safety risk to R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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