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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:53:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230825145457
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: 57DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caress BrownTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not seek medical attention for a resident in its care.
Facility failed to report resident's scabies to Licensing.
Facility failed to notify responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Caress Brown and explained the purpose of the visit.

This investigation consisted of interviews and record review.

LPA Moleski interviewed facility administrator Kent Mulkey, 13 staff members (S1-S13), five residents (R2-R6), and a hospice nurse.

Nine of the staff members interviewed were direct care staff, medication technicians, and/or licensed vocational nurses (S4, S5, S6, S7, S9, S10, S11, S12, S13).
[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
NARRATIVE
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Among these, S6 said a resident (R1) had scabies. S6 was not sure if R1’s family had been notified, and was not sure if R1 was treated for scabies. In interviews, S4, S5, S9, S10, and S13 said R1 did not have scabies or any rashes. S7 said R1 did not have scabies, but had a rash, and was itchy. S7 was not sure if R1 was being treated for the rash. S11 said R1 did not have scabies, but said R1 had redness on the chest and back. S11 was not sure what the redness was caused by, and was not sure what treatments R1 received for the redness. S12 said R1 was never confirmed to have had scabies, but was itchy.

LPA Moleski interviewed five residents (R2-R6). None of the residents remembered R1.

LPA Moleski reviewed R1’s file. R1’s Medication Administration Records (MARs) for the months of July through October 2023 did not show any treatments for scabies. R1’s centrally stored medication records dated between 1/4/23 and 10/23/23 did not show any medications that treat scabies. LPA Moleski reviewed a line listing of residents provided by the facility that identified R1 as “asymptomatic.” The line listing states that R1 received a dose of an antiparasitic medication on 8/10/23. Mulkey and S3 said this was a prophylactic treatment.

LPA Moleski reviewed progress notes written by facility staff dated between 4/30/23 and 10/25/23 and hospice notes dated between 7/31/23 and 10/24/23. A progress note written by staff on 8/10/23 stated that “Resident received” an antiparasitic medication “for prophylactic tx of scabies.” A progress note written on 10/11/23 states that there were “no skin concerns at this time.” A series of notes written between 10/2/23 and 10/16/23 describe "redness" to R1’s groin and genitalia, which did not cause signs or symptoms of pain or discomfort, according to the notes. Hospice nurses treated the area with barrier cream, according to the notes. A progress note written on 10/20/23 states that there were "no skin issues reported at this time." No further notes describe any skin issues.

In interviews, Mulkey, S2, S3, S4, S5, S6, S9, S10, and S11 said residents were treated prophylactically. Mulkey, S2, S5 and S9 said prophylactic treatments were attempted for as many residents as possible, as a precaution. S3 said prophylactic treatments were arranged for asymptomatic residents. S4 and S10 said residents suspected of having scabies were treated. S11 said residents at high risk for scabies or who had unidentified rashes were treated. S12 said only residents who had scabies were treated.

[continued on 9099-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
NARRATIVE
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In an interview, a hospice nurse who worked with R1 said R1 did not have scabies.

The department has determined the following as it relates to the allegations that the facility did not seek medical attention for a resident in its care, that the facility failed to report a resident's scabies to the Community Care Licensing Division, and that the facility failed to notify responsible party:

Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Brown.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230825145457

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: 57DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caress BrownTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to assist with medication administration.
Facility failed to follow its infection control plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Caress Brown and explained the purpose of the visit.

The Community Care Licensing Division previously investigated this facility regarding an allegation that facility staff did not follow protocol when dealing with an infectious disease outbreak. That allegation was substantiated on 10/27/23, and citations were issued as a result of that investigation. LPA Kimberly Viarella found the following:

“On 7/28/23 CCL received notification from SCPHD that El Rio Memory Care had a resident with a suspected case of scabies on 07/27/23. The resident had a rash, scabs, and blood on their clothing. The resident was prescribed a medication for scabies by their primary care doctor. SCPHD sent an email to El Rio Memory Care with guidance for control, treatment, and disinfection. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
NARRATIVE
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 They also included a Scabies Line List that the facility was instructed to complete with resident and or staff information. On 08/08/23, an unannounced collaborative visit was made to El Rio Memory Care by Licensing Program Analyst, (LPA) Kimberly Viarella, and representatives from Stanislaus County Public Health Department, Zaurina Jones, Public Health Nurse, and Gorlia Xiong, Medical Investigator. The LPA identified herself and her colleagues and asked to speak with the Executive Director. The group explained the purpose of their visit was to provide technical support in addressing the recent scabies outbreak. This visit was informational and educational.
The team met with Kent Mulkey, Executive Director, Karan Bassi, Director of Resident Services, and Carlin Robertson, the Campus Business Office Manager. The DRS shared the current practices and procedures that were being implemented to address and prevent the spread of scabies. The SCPHD representatives shared strategies for improving these procedures and offered additional suggestions to assist with eradicating scabies from the facility.

These strategies included but were not limited to the following:
Separate those who have never been treated / shown symptoms from those who have been treated /shown symptoms as much as possible. On 08/08/23, during the collaborative visit with SCPHD, the DRS Karan Bassi, at the time, informed the group that they were practicing social distancing throughout the community in order to prevent more residents from contracting scabies. This LPA observed an activity taking place in the dining room where more than 12 residents were sitting in a circle shoulder to shoulder less than 6 inches apart.
On 8/21/23, Stephen Sarine, Regional Director of Operations (RDO) sent a letter to CCL acknowledging that they had a total of 8 cases, the last dated 8/2/23. According to the LIC 9282 that was submitted to CCL by El Rio Memory Care, their own Emergency Infection Control Plan states the following on page 4.
Under section C:
1: Enhanced environmental cleaning and disinfection. Effective environmental cleaning strategies, and the locations where deep cleaning was needed, were not communicated to the PPD
There shall be separation and/or cohorting of residents as needed. LPA did not witness any separation / social distancing or cohorting during multiple visits on: 08/03/23, 10/3/23 and 10/18/23.

[continued on 9099-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
NARRATIVE
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2: Isolate residents / use contact precautions until treated. None of the residents were isolated.
Treat residents and staff and monitor post treatment for effectiveness. During this investigation, this LPA found multiple instances where residents had to be treated for scabies more than once. One individual was treated more than 3 times since March.
Identification of contacts of symptomatic case(s). Questionnaires were never utilized, and visitors and families were not contacted. El Rio Memory Care was not adhering to its own infection control plan as evidenced by the information provided above. … It was encouraged by the team that signage be posted in the lobby regarding potential exposure to scabies upon entering the community. SCPHD also offered to share a template of a letter that could be utilized to share this information with the family members and responsible parties for all the residents in care. The facility did not request this information, and letters were not sent out to responsible parties for residents in care. SCPHD also suggested developing questionnaires to assist in gathering information from those who have visited or who intend to visit the facility. This LPA visited the facility on: 08/08/23, 10/03/23 and 10/18/23 and did not observe any signage regarding the outbreak. Based on interviews with 5 out of 6 responsible parties, El Rio Memory Care did not notify them of their family members’ change of condition requiring scabies treatment. The facility also did not develop or send out any questionnaires.”

The allegation that this facility failed to follow its infection control plan has already been substantiated, as described above, and citations have already been issued. No new citations will be issued as a result.

The investigation into the allegation that the facility failed to assist with medication administration consisted of record review.

LPA Moleski reviewed R1’s file. A doctor’s note written on 8/9/23 prescribed R1 to take six 3 milligram tablets of an antiparasitic medication, and then to take six more tablets one week after the first dose.

LPA Moleski reviewed a scabies line listing provided by the facility. According to the line listing, R1 was given a treatment of antiparasitic medication on 8/10/23. The line listing contains a column indicating the dates of second treatments. The author of the line listing wrote “N/A” under this column for R1. Based on a treatment date of 8/10/23, R1 should have received a second dose of the antiparasitic medication on 8/17/23.

[continued on 9099-C]

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
NARRATIVE
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LPA Moleski reviewed medication administration records for R1 for the month of August 2023. The antiparasitic medication as described above was not listed on the medication administration records. LPA Moleski reviewed R1’s centrally stored medication records dated between 1/4/23 and 10/23/23. The antiparasitic medication is not listed anywhere in the centrally stored medication records.

LPA Moleski reviewed this facility’s plan of operation. The plan of operation’s medication procedures state that: “Every medication brought into the facility should be recorded on the centrally stored medication record…” and that “All continuous, one time and PRN medications are recorded each time they are passed to a resident.”

LPA Moleski reviewed progress notes for R1 written by facility staff dated between 4/30/23 and 10/25/23. A note written on 8/10/23 states that “resident received” antiparasitic medication “for prophylactic tx of scabies.” The following note, written on 8/20/23, makes no mention of any second dose of the antiparasitic medication being given to R1.

The department has determined the following as it relates to the allegation that the facility failed to assist with medication administration:

Based on record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87465(a)(4). An exit interview was held with Brown. Appeal rights and a copy of this report was left with Brown.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20230825145457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87465(a)(4)
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"The licensee shall assist residents with self-administered medications as needed."

This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding medication administration and medication record-keeping by the POC due date. Licensee agrees to email LPA Moleski a copy of the training sign-in sheet.
vincent.moleski@dss.ca.gov
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Based on record review, R1 was not given a second dose of antiparasitic medication as ordered by a physician, which poses an immediate health and safety risk.
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8