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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500301453
Report Date: 05/19/2022
Date Signed: 05/19/2022 01:00:43 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
02/22/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220222132937
FACILITY NAME:COVENANT LIVING OF TURLOCKFACILITY NUMBER:
500301453
ADMINISTRATOR:RYAN HUSTFACILITY TYPE:
741
ADDRESS:2125 N OLIVE AVENUETELEPHONE:
(209) 632-9976
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:377CENSUS: 271DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Ryan Hust and Assisted Living Director Melina NunezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Covid-19 protocols were not followed

Medical attention for resident(s) not sought in a timely manner
INVESTIGATION FINDINGS:
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LPA Jason Lund arrived at the above facility unannounced to complete a complaint investigation. LPA Lund met with Executive Director Ryan Hust and Assisted Living Director Melina Nunez and explained the purpose of today's visit.

Medical attention for resident(s) not sought in a timely manner- During the course of the investigation, through medical records review, death report, and staff interviews. On 2/10/2022 Resident (R1) tested positive for COVID-19. On 2/11/2022 R1 vitals were checked, and it revealed R1 had a fever and oxygen level was low. R1 was sent to Emanuel Medical Center on 2/12/2022 after R1 symptoms had worsened. R1 passed away on 2/19/2022 at Emanuel Medical Center. The facility failed to seek medical attention in timely for R1.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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 4
Control Number 27-AS-20220222132937
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: COVENANT LIVING OF TURLOCK
FACILITY NUMBER: 500301453
VISIT DATE: 05/19/2022
NARRATIVE
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Covid-19 protocols were not followed- Based on interviews and documents collected during the course of this investigation, it was learned that Resident (R1) tested positive for COVID-19 on 2/10/2022. On 2/11/2022 R1 vitals were checked, and it revealed R1 had a fever and oxygen level was low. On 2/12/2022 R1 was sent to Emanuel Medical Center. The facility failed to send R1 to the hospital when R1’s vitals were out of normal range.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations.

You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in death of a resident, or that constitutes physical abuse of a client.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of R1 care while at the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
02/22/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220222132937

FACILITY NAME:COVENANT LIVING OF TURLOCKFACILITY NUMBER:
500301453
ADMINISTRATOR:RYAN HUSTFACILITY TYPE:
741
ADDRESS:2125 N OLIVE AVENUETELEPHONE:
(209) 632-9976
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:377CENSUS: DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Ryan Hust and Assisted Living Director Melina NunezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Questionable Death.
INVESTIGATION FINDINGS:
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The investigation included review of facility records, death report. interviewed staff and witnesses regarding the above allegation.
Questionable Death- Based on interviews with staff, witness, and review of records, Resident (R1) tested positive for COVID-19 and showed mild symptoms. On 2/12/2022 R1 was sent to the hospital and on 2/19/2022 passed away. The signed death certificate stated, it was not neglect, but R1 age,causing R1 to rapidly decline, which caused R1 to expire.
Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview was conducted with Executive Director Ryan Hust and Assisted Living Director Melina Nunez. A copy was left and appeal rights given.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220222132937
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: COVENANT LIVING OF TURLOCK
FACILITY NUMBER: 500301453
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator will arrange for training and clear by 5/20/2022 POC date.
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The following requirement has not been met as evidenced by: The facility failed to send R1 to the hospital when R1’s vitals were out of normal range. Which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
05/20/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608....,
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Administrator will arrange for training and clear by 5/20/2022 POC date.
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The following requirement has not been met as evidenced by: The facility failed to seek medical attention in timely for R1. Which poses an immediate health, safety or personal rights risk to residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4