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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:40:37 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
07/22/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220722081517
FACILITY NAME:ARBOR PLACEFACILITY NUMBER:
397004353
ADMINISTRATOR:BELINDA GUZMANFACILITY TYPE:
740
ADDRESS:17 LOUIE AVETELEPHONE:
(209) 369-8282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:76CENSUS: 48DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Rose MarreroTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Licensee did not notify responsible party of changes in resident condition
Licensee increased resident rate without a 60 day notice
INVESTIGATION FINDINGS:
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On 9-29-22 at 9:55am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a complaint investigation for the allegations noted above. LPA met with assistant business office manager Rosa Marrero and explained the purpose of the visit. Administrator Belinda Guzman was made aware of LPA’s visit via phone. LPA interviewed Administrator via phone and assistant business office manager, LPA also reviewed facility file documentation including Admission agreement for resident1 (R1), pre-placement appraisal for R1, needs and services plans for R1, medication log sheets for R1, physician orders for R1, care notes for R1, incident reports for R1, and level of care rate change notice for R1.

Allegation #1: Licensee did not notify responsible party of changes in resident condition. LPA interviewed Administrator and assistant business office manager in addition to documentation as noted above. Based on interviews and record reviews, it was determined that R1 had a change in condition not previously identified during R1’s initial admission. LPA reviewed needs and service plans dated 6-21-21 and 7-8-22. {Cont. on 9099C}.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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 3
Control Number 27-AS-20220722081517
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: ARBOR PLACE
FACILITY NUMBER: 397004353
VISIT DATE: 09/29/2022
NARRATIVE
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The needs and service plan dated 7-8-22 indicated the change in condition for R1. Upon further review, it was determined that R1’s responsible party’s signature was not included on the needs and service plan dated 7-8-22. Medication log sheets and physician orders reviewed revealed medication Seroquel prescribed on 5-2-22 at 25mg twice per day, then increased to 50mg twice per day on 5-5-22. due to a change in condition for R1. Furthermore, based on interview and record review, there is no indication of a reappraisal with a meeting arranged to discuss significant changes in condition. Upon further record review and interview, there is no additional form of communication to indicate R1’s responsible party was notified of a change in condition leading to this medication change. Based on interviews and records reviewed, there is a preponderance of evidence to conclude R1’s responsible party was not properly notified of R1’s change of condition, therefore this allegation is SUBSTANTIATED.

Allegation #2: Licensee increased resident rate without a 60-day notice. LPA interviewed Administrator and assistant business office manager. LPA also reviewed Admission agreement for R1, annual rate increase notice for R1, needs and service plan for R1, medication log sheets for R1, and care notes for R1. Allegation noted above addresses an annual rate increase for residency. Based on review of admission agreement under “Notice of Rate Changes”, there is no documented language stating R1’s rate will increase annually. Based on interviews and record reviews, it was determined that R1 began experiencing a change of condition after initial admission date on 5-19-21. New medication orders for Seroquel were received by facility on 5-2-22 and 5-5-22 due to R1’s change of condition. Rate change notices reviewed indicate a rate increase to begin on 7-1-21 with an acknowledgement from R1’s responsible party on 7-6-21.Furthermore, this notice did not indicate a general description of the additional costs and the reason for the increase. Based on interviews and record reviews, there is a preponderance of evidence to conclude R1’s responsible party did not receive a proper 60-day notice of increased rate per regulatory requirements. Therefore, this allegation is SUBSTANTIATED.

As a result of this investigation, citations are issued under Title 22, Division 6, Chapter 8 and Health and Safety Codes. An exit interview was conducted with Rosa Marrero and a copy of this report was left with Rosa. Appeal rights explained and to be provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220722081517
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: ARBOR PLACE
FACILITY NUMBER: 397004353
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
87463(c)
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87463(c) Reappraisals. (c)The licensee shall arrange a meeting with the resident, the resident’s representative...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first…This requirement is not met as evidenced by:
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Licensee will read regulation 87463(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, licensee did not ensure a meeting was arranged with R1’s representative for purposes of discussing changes in condition. This posed a potential health, safety, and resident rights risk to residents in care.
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Licensee to submit a plan describing how residents and residents’ representatives are notified properly of changes in condition. Plan to be submitted to LPA by POC due date.
Type B
10/10/2022
Section Cited
HSC
1569.655(a)
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Increase in fees...(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs…This requirement is not met as evidenced by:
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Licensee will read regulation 1569.655(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, licensee did not ensure a proper 60-day notice of rate increase was given to R1’s representative. This posed a potential health, safety, and resident rights risks to residents in care.
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Licensee to submit a plan describing how residents and residents’ representative are notified properly of 60-day rate increases. Plan to be submitted 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3