397004544-7-5-2023-27-AS-KHOS-CU5TTM-20230727150056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004544
Report Date: 07/05/2023
Date Signed: 07/05/2023 09:37:21 PM

Unsubstantiated

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
03/30/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230330170441

FACILITY NAME:	MEADOW CREEK VILLA		FACILITY NUMBER:	397004544
ADMINISTRATOR:	MELVIN SERBAN		FACILITY TYPE:	740
ADDRESS:	4930 MOORCROFT CIRCLE		TELEPHONE:	(209) 982-4262
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	6	CENSUS: 5	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	S.Melvin		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident developed a severe pressure injury while in care.
Facility is monitoring residents phone calls.
Facility is limiting residents visits.
Facility is not providing activities to residents in care.
Facility did not ensure resident was properly clothed.

INVESTIGATION FINDINGS:

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The department has investigated the above allegations and all have been determined to be Unsubstantiated.

Allegation: Resident developed a severe pressure injury while in care. On 03/21/2023, R1 was transported to St. Joseph Medical Center. R1 was diagnosed with a stage three
pressure injury on her coccyx and was discharged on 03/22/2023. On 03/25/2023, R1 was transported to St. Joseph Medical Center based on positive blood culture results. On 03/29/2023, R1 died.

Facility staff indicated that they first noticed the wound on 03/13/2023. On 03/15/2023, facility staff contacted R1s family, R1's primary care physician (PCP), and Sky Healthcare Home Health Services. Facility staff contacted R1's family and made attempts to contact R1's PCP beginning on 03/15/2023 until 03/21/2023,
when R1 had a video appointment. At the conclusion of the video appointment, R1 was transported to the hospital and home health services was ordered.
R1 was discharged after a sample of blood cultures were taken on the morning of 03/22/2023 and prescribed antibiotics. On 03/24/2023, a home health registered nurse (RN) went to the facility and provided wound care.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230330170441

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: MEADOW CREEK VILLA	FACILITY NUMBER: 397004544
	VISIT DATE: 07/05/2023

NARRATIVE

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At the conclusion of the video appointment, R1 was transported to the hospital and home health services was ordered. R1 was discharged after a sample of blood cultures were taken on the morning of 03/22/2023 and prescribed antibiotics. On 03/24/2023, a home health registered nurse (RN) went to the facility and provided wound care.

On 03/25/2023, the hospital contacted R1's family and advised that R1 be sent to the hospital because blood cultures were positive for infection. R1 was at her baseline when transported to the hospital. R1 remained at the hospital and was placed on hospice and died on 03/29/2023.

Allegation: Facility is monitoring residents phone calls. Based on interviews conducted with the staff, they all denied listening in on calls or monitoring calls from family or anyone else when residents are on the phone. The landlines are in the main areas of the facility. LPA also interviewed family and was unable to confirm that the calls are being monitored based on interviews with family and available information.

Allegation: Facility is limiting residents visits. Based on interviews conducted with families of residents, the facility has records of visits from the families and interviews with those families confirmed that visits are not limited unless the residents wants to end the visit or family chooses to end the visit. Staff stated that they allow the families to visit and the visit vary according to the resident and how they are feeling that day. During the pandemic the facility was following guidelines that were established by the departments of the state. Some of those Covid related requirements were more stringent.

Allegation: Facility is not providing activities to residents in care.
The facility does not have an activity calendar (not required for a six bed facility 87219(d)) and the Staff/residents confirmed that there are no coordinated activities, however, the residents have the option to listen to music, walk in the back yard, explore the internet on their tablets or watch television.

Allegation: Facility did not ensure resident was properly clothed.
Based on interviews with the Administrator the stated that the resident preference was to wear loose gown to manage her toilets needs. R1 was wearing regular gown prior to November 2022, The facility provided hospital gown as a result of R1 refusal to get out of bed and the onset of more incontinence issues.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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