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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500312416
Report Date: 07/16/2021
Date Signed: 07/17/2021 09:39:53 AM

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:ORANGEBURG MANORFACILITY NUMBER:
500312416
ADMINISTRATOR:MARIE ARBIOSFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:0CENSUS: 54DATE:
07/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Marie Arbios, Executive DirectorTIME COMPLETED:
03:20 PM
NARRATIVE
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LPA Bruce Jacobs conducted an unannounced inspection to this facility to issue a clition for not following the requirements for training of staff who care for residents with dementia. LPA met with Executive Director Marie Arbios and informed ED of the purpose of the visit. LPA reviewed the personnel records for two staff involved in an incident in May 2020. The incident and a corresponding complaint was investigated by the Department and it was determined that two staff in the dementia unit momentarily left a resident unattended in the shower area. The resident fell off a shower chair, suffered a head contusion, cervical fractures, was hospitalized and died in the hospital. The Department determined that the fall and injuries were directly related to the resident's death and the staff did not properly supervise the resident. LPA spoke to the Executive Director and reviewed facility training records and determined the facility did not have proof of the required dementia training for the two staff identified in the complaint report.

A deficiency is issued on the following LIC 809 for not following the Training Requirements of CCR 87707 regulations.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ORANGEBURG MANOR
FACILITY NUMBER: 500312416
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2021
Section Cited

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Training Requirements If Advertising Dementia Special Care. (a) Licensees...providing special care.. for residents with dementia or related disorders shall ensure that all direct care staff... who provide care to residents with dementia, meet the following training requirements: Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of
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that date and in each succeeding 12-month period. This requirement was not met as staff S-1 had documentation of two hours of dementia and staff S-2 did not have any documented hours. This is a potential Health and Safety risk to clients in care.
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The Facility Administrator has informed Licensing that dementia training for the identified staff is current and will send proof that the requirements are met

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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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