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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:22:35 PM


Document Has Been Signed on 10/03/2023 04:22 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 59DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karan BassiTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/03/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced Case Management visit to discuss resident on resident altercations involving R1, specifically LIC 624s dated 07/26/23 and 8/21/23.

LPA identified herself, the reason for the visit and asked to speak with the Designated Facility Administrator. LPA proceeded to tour the facility with Carlin Robertson, the Business Office Manager, and Karan Bassi, the Director of Residential Services.

LPA observed 18 residents in the Rose Dining Room participating in the Sunshine Club. This LPA also viewed 5 resident rooms where the bedding and mattresses were inspected along with the contents of resident bathrooms. This LPA also observed staff de-escalate 2 distressed residents: the first displayed general anxiety and the second was convinced someone stole her lunch.

The LPA reviewed the LIC 602 for R1, and it had not been updated since 03/03/2021. LPA requested R1’s needs and services plan for 07/26/23 as well the plan currently being utilized. In the plan dated 04/28/23, it states that R1 should be getting safety checks 4 times per shift. In the plan dated 8/31/23 it states that R1 should be getting safety checks every hour. With regard to the section titled,” Disposition and Behaviors” there were no changes to the existing plan. It stated, “Occasional intervention to de-escalate” and lists that the resident may be, “Physically disruptive (pushing, biting, throwing, or hitting) and that R1 had a, “History of physical Aggression or violence.” On the final page of the report it scores the needs of the resident by category. For the category Disposition and Behaviors, R1 scored a 6 on the report compiled on 04/2'8/23. After 2 resident on resident altercations, one in which the police were called to the scene, nothing in R1s care plan had changed. LPA requested copies of the EMAR for R1s medications for 07/26/23 as well as what R1 was currently being prescribed. They were almost identical with the only differences being that back in July, R1 was taking more medications for digestive issues and a skin rash. The LPA also reviewed the LIC 602 and it had not been updated since 03/03/2021.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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 3


Document Has Been Signed on 10/03/2023 04:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
87705(c)(5)(A)

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Care, Persons with Dementia 87705(c)(5)(A) (5) Each resident with dementia shall have an annual medical assessment...(A) When any... appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care...
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Licensee shall identify all the residents requiring updated annual LIC 602's as well as those needed due to change in behavior or condition. Licensee will submit this list to kimberly.viarella@dss.ca.gov by 10/14/2023.
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This requirement was not met as evidenced by:
Dementia care resident has not had a new LIC 602 since 3/3/2021 and the licensee failed to update the needs and services plan of R1 after R1 was involved in 2 separate resident on resident altercations.
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Type A
10/04/2023
Section Cited
CCR87705(c)(4)

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Care, Persons with Dementia 87705(c)(4)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff...resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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The Licensee shall revisit R1's care plan to determine ways to reduce overstimulation by redirecting R1 to a less populated area /activity. Licensee shall submit new care plan to kimberly.viarella@dss.ca.gov by 10/4/2023.
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This requirement was not met as evidenced by:
Sufficient staffing would have provided the opportunity for staff to redirect R1 before either of the 2 situations escalated to violence. Per R1's appraisal, R1 "has a history of physical aggression or violence."
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
VISIT DATE: 10/03/2023
NARRATIVE
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Deficiencies were observed and cited during this case management visit and have been cited on the LIC 809 D page.

Appeal Rights provided, Exit interview.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3