<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 02/14/2023
Date Signed: 02/14/2023 03:35:18 PM


Document Has Been Signed on 02/14/2023 03:35 PM - 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:EL RIO MEMORY CARE COMMUNITYFACILITY NUMBER:
502700235
ADMINISTRATOR:KEATON, MARYFACILITY TYPE:
740
ADDRESS:2828 HEALTHCARE WAYTELEPHONE:
(209) 543-3805
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:72CENSUS: 60DATE:
02/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mary KeatonTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2-14-23 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit relating to previous COVID-19 positive cases. LPA met with Administrator Mary Keaton and explained the purpose of the visit and conducted an interview with Administrator. Based on interview conducted, it was determined that a total of 15 residents and 2 staff members had positive COVID-19 test results between the dates of 1/31/22 and 2/13/22. It was further determined through record review and interview, that these cases were reported to local health department, but not reported to licensing department per regulatory requirements. It was further determined through interview that there are no current active COVID-19 cases and facility has been cleared by local health department since 2-13-23.

As a result of today's case management, citation is issued under Title 22, Division 6. An exit interview was conducted with Mary Keaton and a copy of this report was left with Mary. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/14/2023 03:35 PM - It Cannot Be Edited

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: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2023
Section Cited

1
2
3
4
5
6
7
Reporting requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including :(2) Occurrences, such as epidemic outbreaks...within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee or designee will conduct staff training on reporting requirements and submit scheduled training date to LPA by POC due date. Training to be completed no more than 2 weeks from date of citation issuance, and proof of completed training to be submitted to LPA prior to citation clearance.
8
9
10
11
12
13
14
Based on interview, facility had a total of 15 resident and 2 staff active covid cases between 1/31/22 and 2/13/22 which were not reported to licensing department. This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee or designee to submit information on previous active COVID cases to LPA by POC due date. Licensee may utilize COVID reporting template provided by LPA during today's visit.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2