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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500312416
Report Date: 05/14/2021
Date Signed: 05/18/2021 10:24:22 AM



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
05/22/2020 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200522160700
FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
500312416
ADMINISTRATOR:MARIE ARBIOSFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:90CENSUS: 21DATE:
05/14/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marie Arbios, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Severe neglect resulted in a resident's death

Resident sustained a fracture while in care due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bruce Jacobs contacted Executive Director Marie Arbios to deliver investigation findings on the above allegations. This investigation was conducted by LPAs Bruce Jacobs and Martin Schreiber and consisted of site inspections and interviews with the facility Executive Director (S-3) and care staff (S-1,2). Medical and facility records were obtained and reviewed. Other witnesses were contacted and interviewed.

This investigation concluded that the facility staff (S-1,2) was giving resident (R-1) a shower on the morning of May 7th, 2020. The resident was in a shower chair at the time. One caregiver (S-1) was assisting the resident with the shower and the other caregiver was nearby, but not in the shower area. The caregiver (S-1) stepped away from the resident momentarily and the resident slipped off the shower chair and falling on the shower floor, sustaining injuries. The resident was taken to the hospital on 5/7/20 and was diagnosed with a head abrasion and cervical fractures. The resident remained in the hospital and passed away on 5/11/20.

(continued)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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-20200522160700
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: ORANGEBURG MANOR
FACILITY NUMBER: 500312416
VISIT DATE: 05/14/2021
NARRATIVE
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Interviews and records document that the resident was a fall risk and the resident was hospitalized after the fall. The resident's care plan called for shower assist and care staff briefly stepped away from the resident at which time the resident slipped off the shower chair, fell and was injured. The resident hit her head and had a head contusion and abrasion. The resident was transported to the hospital where the resident was diagnosed with cervical fractures in addition to the head injury. The resident remained at the hospital and passed away on May 11th. The cause of death on the death certificate was listed as cardiopulmonary arrest, cervical spine fractures and ground level fall.

As a result of this investigation, Licensing has determined the above allegations are (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 deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49.

Exit interview conducted and report provided. Appeals rights printed
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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
05/22/2020 and conducted by Evaluator Bruce Jacobs
COMPLAINT CONTROL NUMBER: 27-AS-20200522160700

FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
500312416
ADMINISTRATOR:MARIE ARBIOSFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:90CENSUS: 21DATE:
05/14/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marie Arbios, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility failed to address lice issue regarding resident.

Resident sustained multiple falls while in care due to neglect.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bruce Jacobs contacted Executive Director Marie Arbios to deliver investigation findings on the above allegations. This investigation was conducted by LPAs Martin Schreiber and Bruce Jacobs and consisted of site inspections and interviews with the facility Executive Director (S-3) and care staff (S-1,2). Medical and facility records were obtained and reviewed. Other witnesses were contacted and interviewed.

This investigation concluded that while the facility had a problem with bedbugs at the facility, the facility took multiple steps to eradicate the infestation. Professional exterminators were call in several times and the facility took multiple steps to address the problem. The outbreak was reported to both Licensing, the County Department of Public Health and the residents' physicians. For the allegation that the resident sustained multiple falls as a result of neglect, this allegation was investigation and it was determined that that while there are three documented falls in the resident's records, only one fall was as a result of neglect and that incident is addressed and cited as a deficiency in a separate report.

Therefore, there is not a preponderance of evidence to be able to substantiate the above allegations and the department finds the allegations are UNSUBSTANTIATED
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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-20200522160700
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: ORANGEBURG MANOR
FACILITY NUMBER: 500312416
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/24/2021
Section Cited
CCR
87464(d)
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Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was
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Plan of Correction: Facility Administrator will develop a plan to ensure that the staffing is sufficiently trained on the resident's care plan and the plan is followed Also, care staff are properly trained to perform their basis duties to meet the needs of residents. A written Plan of Correction detailing how the facility will
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not met as evidenced by: The resident (R-1) was assessed as a fall risk upon admission and the resident had a serious fall with injuries while left unattended in the shower. The resident fell on 5/7/20, was hospitalized, had cervical fractures and passed away in the hospital on 5/11/20. The facility failed to provide additional safety measures to prevent falls.
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implement an adequate procedure to assess and meet the resident's need. POC due by 05/19/21 and completed by 06/12/21 as the resident has passed and there is no longer an immediate health and safety risk.
This violation was an immediate health and safety risk to the residents in care at the time of the incident and injury.
Deficiency Dismissed
Type A
05/24/2021
Section Cited
CCR
87464(d)
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Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was
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Plan of Correction: Facility Administrator will develop a plan to ensure that the staffing is sufficiently trained on the resident's care plan and the plan is followed Also, care staff are properly trained to perform their basis duties to meet the needs of residents. A written Plan of Correction detailing how the facility will
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not met as evidenced by: The resident's (R-1) care plan called for shower assist. The resident had a serious fall with injuries while left unattended in the shower. The resident fell on 5/7/20, was hospitalized, had cervical fractures and passed away in the hospital on 5/11/20. The facility failed to follow the care plan leading to the fall.
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implement an adequate procedure to assess and meet the resident's need. POC due by 05/19/21 and completed by 06/12/21 as the resident has passed and there is no longer an immediate health and safety risk.
This violation was an immediate health and safety risk to the residents in care at the time of the incident and injury.
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: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4