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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:48:47 PM


Document Has Been Signed on 08/22/2023 03:48 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:EL RIO MEMORY CARE COMMUNITYFACILITY NUMBER:
502700235
ADMINISTRATOR:KENT E MULKEYFACILITY TYPE:
740
ADDRESS:2828 HEALTHCARE WAYTELEPHONE:
(209) 543-3805
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:72CENSUS: 62DATE:
08/22/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Steve Sarine, Regional Director of Operations TIME COMPLETED:
03:00 PM
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A Non-Compliance Conference (NCC) was conducted on this day, 08/22/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to discuss existing deficiencies, problem areas in the operation of the facility, and ways to bring the facility into compliance as to avoid legal action.

Present at the meeting were Regional Office Manager (RM), Stephenie Doub, Licensing Program Managers (LPMs) Liza King and Stephen Richardson, and Licensing Program Analysts (LPAs), Kimberly Viarella and Jason Lund. Representing Koelsch Senior Communities were Eva Arant, Chief Operating Officer, Michelle Baker, Vice President of Operations, Steve Sarine, Regional Director of Operations – CA, Kayleen August, Regional Director of Nursing – CA, and Kent Mulkey, Executive Director, El Rio Memory Care. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process.

The focus of the concerns at this time:

  • Reporting Requirements
  • Assessment and Reassessment
- Restricted Health Conditions
- Resident on Resident (R:R) Altercations
  • Outbreak Infestations

The Licensee agreed to do the following in order to bring the facility into compliance by the following dates:

· The presence of an Administrator 40 hours a week.


· Conduct training related to the following every 6 months for a year then annually thereafter. Proof of
training to include name of trainer, topics covered with duration of training, and list of all attendees.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
VISIT DATE: 08/22/2023
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 Documentation shall be available for review by Community Care Licensing (CCL) during increased
monitoring visits.
- Reporting Requirements (All staff)
- Restricted Health Conditions (Care Staff)
- Wound Stages (Care Staff)
- Facility Protocols re: Outbreaks and Infestations (All staff)
* Scabies
· Maintain facility pest inspection reports accessible to CCL staff

During the conference, Licensing requested the following documents by the close of business on 08/24/2023.
  • All in-service trainings from January 1, 2023 to present
Including a copy of the reporting requirement trainings that were already conducted
  • A copy of the policy outlining how and when to call 911 (especially if the Med Tech does not think it is necessary)

Community Care Licensing agreed to take the following steps to assist the facility in achieving and maintaining compliance:
  • CCL will provide additional quarterly monitoring and facility inspections to verify improvement incompliance.
  • Provide TSP services agreed upon during this meeting.
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Failure to maintain substantial compliance outlined on LIC 9111 dated 08/22/2023 may result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.

Exit interview conducted, and copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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