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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500312416
Report Date: 12/08/2022
Date Signed: 12/08/2022 10:09:46 AM


Document Has Been Signed on 12/08/2022 10:09 AM - It Cannot Be Edited

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: 0DATE:
12/08/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Chief Executive Officer (Licensee) Mark Cimino TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Jason Lund conducted an announced complaint visit on 12/8/2022 located at 3401 Walnut Ave, Sacramento, 95608 to follow up on a substantiated allegation of neglect and lack of supervision that led to a serious injury and death of a resident (R1). LPA Jason Lund met with Chief Executive Officer (Licensee) Mark Cimino. This facility number has been closed due to a change of ownership and the facility has obtained a new license number under the same facility name.

On May 14, 2021, the Department concluded a complaint investigation which alleged the following: R1 fell at the facility, sustained cervical (neck) fractures, and subsequently died at the hospital as a direct result of the fall.

The allegations of neglect resulting in R1's death and sustained fracture(s) while in care due to neglect were investigated and substantiated. The licensee was cited for violating California Code of Regulations (CCR) CCR Title 22, § 87464(d) - Basic Services for not meeting the resident’s needs, including adequate supervision (neglect) resulting in the resident sustaining a fall causing multiple injuries. Per the Consultation Notes dated May 7, 2020, obtained from the acute hospital, R1’s injuries included a forehead abrasion and a traumatic hematoma of forehead, skin tears to the left arm and C1 and C2 cervical fractures. According to John Hopkins University, a cervical fracture is a broken bone in the cervical (neck) region of the spine. John Hopkins University also describes that a hematoma is a blood-filled mass resulting from an injury. These injuries were contributing factors to R1’s death as documented on the death certificate. Allegations of R1 sustaining multiple falls due to neglect and failing to address a lice infestation were not substantiated.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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
VISIT DATE: 12/08/2022
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According to the Physicians Report dated June 3, 2019, R1’s diagnosis included dementia and was unable to make their needs known. Facility records including the Level of Care Assessment completed on February 19, 2020, and incident reports of falls on February 4, 2020, February 14, 2020, and March 6, 2020, document that R1 was a fall risk and had a history of falls. Interviews with the Facility Administrator, staff, and other witnesses confirmed they were aware of R1 being a fall risk and had a history of falls. R1’s care plan dated February 19, 2020, also identifies R1 as having mild to severe Aphasia and unable to communicate. R1’s care plan identified the need for assistance with activities of ambulating, dressing, hygiene as well as shower assist. In addition, the care plan documented R1’s preference of afternoon showers. On the morning of May 7, 2020, records and interviews stated that R1 was agitated. The investigation concluded that facility staff (S1, S2) were giving R1 a shower on May 7, 2020, at 6:25 A.M. R1 was seated on a shower chair at the time. S1 was directly assisting R1 in the shower area and S2 had stepped away from the bathroom area to gather supplies. S1 then stepped away from R1 momentarily to get shampoo at which time R1 fell off the shower chair and onto the floor, sustaining injuries. R1 was taken to the hospital on May 7, 2020 and was diagnosed with an accidental fall; C1 and C2 cervical fracture, forehead abrasion and traumatic hematoma of the forehead.

R1 remained in the hospital from May 7, 2020 and passed away on May 11, 2020. The Department obtained and reviewed R1’s medical records and death certificate. According to hospital documentation, neurosurgery recommended against any surgical intervention, and recommended a hard collar for life. However, R1 was unable to speak or swallow, known as dysphagia. According to the National Institute on Health, non-operatively managed patients with C1 fractures are 4 times more likely to have dysphagia. On May 8, 2020, a swallow evaluation was performed by a Speech Pathologist, who attempted a by mouth trial of ice chips. R1 made no attempt to orally manipulate the ice chip in their mouth. The Speech Pathologist recommended nothing by mouth due to the lack of R1’s swallowing reflex. According to the physician’s notes, R1 was identified as having a poor prognosis. According to the Death Report Summary obtained from the acute hospital, R1’s family agreed to comfort care and hospice and R1 was started on low-dose maintenance of morphine. Over the next few days, R1 was unable to eat or drink. On May 11, 2020, at 2:16 A.M., R1 passed at the hospital. The cause of death on the death certificate was listed as cardiopulmonary arrest, cervical spine (neck) fractures and ground level fall. John Hopkins University describes cardiopulmonary arrest as when the heart suddenly stops beating.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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
VISIT DATE: 12/08/2022
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At the time of the complaint visit, on May 14, 2021, the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the death resulting from serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today (date), the Department is issuing a Civil Penalty per Health and Safety code section 1569.49 in the amount of $15,000.00 for a violation that the Department determines resulted in the death of R1.

A copy of the LIC 421D was given to Chief Executive Officer (Licensee) Mark Cimino and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Chief Executive Officer (Licensee) Mark Cimino signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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