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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:33:21 PM

Substantiated


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
07/27/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20230727163804
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: 56DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
12:15 AM
MET WITH:Kent MulkeyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility has an outbreak of scabies.
Staff did not meet resident's hygiene needs.
Staff did not follow protocol when dealing with an infectious outbreak.
Facility did not report the rash to family.
Facility did not report the rash to licensing.
INVESTIGATION FINDINGS:
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On 10/27/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver complaint investigation findings regarding the above allegations. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. The LPA met with Kent Mulkey and a brief interview followed.

Regarding: Facility has an outbreak of scabies:
On 07/27/23 at 4:43 PM, Community Care Licensing (CCL) received a complaint regarding a possible scabies outbreak at El Rio Memory Care. On this same day, LPA Viarella received a phone call from Karan Bassi, the Director of Resident Services (DRS), letting the LPA know that they suspected they might have a resident with scabies. On 08/04/23, the Director sent an LIC 624 stating that they had 4 residents whom they suspected of having scabies, with the first 2 exhibiting symptoms on 07/27/23.
On 8/21/23, Stephen Sarine, Regional Director of Operations sent a letter to CCL that acknowledged that they had a total of 8 cases, the last dated 8/2/23. This LPA had inquired during the visit completed on
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 10
Control Number 27-AS-20230727163804
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: 10/27/2023
NARRATIVE
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10/03/23 if there were any more residents being treated for scabies and both Karan Bassi, the DRS and Carlin Robertson, the Campus Business Office Manager (CBOM), replied, “No.” On 10/18/23, this LPA visited the facility and during the course of this investigation found that 29 additional residents had been treated for scabies symptoms without CCL or the Stanislaus County Public Health Department (SCPHD) being notified.

The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED.

Regarding: Staff did not follow protocol when dealing with an infectious outbreak.


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

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
NARRATIVE
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On 10/018/23 LPA visited the facility and observed a resident (R5) in the main dining room sitting with 3 other residents. R5 was itching and scratching non-stop. LPA brought this to the attention of Kayleen August, the Regional Nurse for Koelsch. LPA suggested checking the resident for scabies. The Regional Nurse confirmed that they had just received a prescription for scabies medication for that R5. R5 was suspected of having scabies and was observed eating in the main dining room with 3 other residents at the table.

Vacuum and deep clean.


SCPHD recommended that vacuuming all flooring, bedding, and furniture, particularly the furniture in common areas like the dining rooms, would assist in limiting the spread of scabies. On 10/18/23 during an interview with the Physical Plant Director (PPD), Jay Duarte, this LPA learned that furniture and bedding had not been vacuumed and that this information had not been passed along to the PPD.

Enhance environmental cleaning procedures.
During the interview with the PPD (also in charge of Housekeeping), on 10/18/23, the PPD shared that they had switched to disposable mop and dust heads based on recommendations from public health. This LPA also learned that he had not been informed of the additional 31 residents who had been treated for scabies symptoms (as of 10/18/23) and whose rooms required a deep cleaning. The Physical Plant Director thought the most recent cases had been treated in August of 2023. The PPD had not been instructed to deep clean the rooms of any of the residents who had been treated for scabies since August. 6 inches apart.

Communication

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.

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

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
NARRATIVE
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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.
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.

The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED.

Regarding: Staff did not meet resident's hygiene needs.


Through interviews conducted during the course of this investigation, this LPA learned that scheduled showers are sometimes not completed due to call-outs. 5 out of 5 responsible parties for individuals treated for scabies stated that they noticed their loved ones scratching at a rash and/or scabs and alerted carestaff. During a facility visit on 10/03/23 this LPA inspected the bedding and mattresses in 5 resident bedrooms. 1 had reddish stains on the sheets as well as on the box spring. Pictures were taken for reference.

Also related to hygiene, 4 out of 7 responsible parties interviewed stated that they had observed their loved ones in soiled or wet briefs for extended periods of time. Interviews with staff revealed that if there were call -outs it could take 3 to 3 and a ½ hours for one caregiver to complete their rounds. This already exceeds the incontinence check required at the 2-hour mark. The LPA also learned during interviews that if there were callouts, that fewer or sometimes none of the scheduled showers might take place that day.

The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED.

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

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
NARRATIVE
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Regarding: Facility did not report rash to licensing.

During the course of this investigation, this LPA reviewed the Medication Records for R5 for July and August. There was a handwritten prescription for Permethrin, a drug used to treat scabies, that was administered on 07/14/23. Community Care Licensing was not informed that this resident was treated as early as 7/14/23. The report we received said that the first 2 cases were noted on 7/27/23. El Rio Memory Care failed to meet reporting requirements when they failed to notify Licensing of the change in residents’ conditions and the resulting need for scabies medication. They did not submit LIC 624s alerting CCL to the continued presence of scabies at the facility. By 08/21/23 there were a total of 29 additional residents that had been treated for scabies symptoms.

The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED.

Regarding: Facility did not report rash to families.

Based on 5 out of 5 interviews with responsible parties, the facility did not notify them of scabies being present in the facility. In 4 out of 5 cases, the responsible parties informed the facility of the rash and suspected presence of scabies. Some residents have been treated more than once. Families were not notified of additional treatments. R5 was treated for scabies in March of 2023. This LPA reviewed the Medication Record and found additional prescriptions for treatment for R5. A handwritten prescription for Ivermectin was in the MAR and given on 07/31/23. LPA found a third handwritten prescription for Permethrin that was given on 09/22/23 and there was a box on the 28th that appeared to indicate that another dose should have been given at that time, exactly 7 days later. This LPA spoke with the new Director of Resident Services and was informed that R5 had received another Permethrin treatment on 10/21/23. This LPA spoke with R5’s responsible party and they were only aware of the treatment in March and thought R5 might need another as they noticed R5 scratching during their latest visit.

The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED.

Deficiencies for the above substantiated allegations were cited on the LIC 9099D page.

A copy of this report was provided along with Appeal Rights. Exit Interview

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

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87211(a)(2)
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Reporting Requirements 87211(a)(2)
(a) Each licensee... to the licensing agency such reports as ... the following:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes... The Licensee failed to comply with the above regulations as evidenced by
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Licensee has already replaced the DRS and going forward will conduct quarterly audits to ensure the new DRS is complying with policy. Licensee will also update Infection Control Policy to include a detailed Scabies section that incorporates SCHP recommendations. Licensee will submit an attestation that
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 Based on records review, interviews and observation, the licensee failed to report an outbreak of scabies within 24 hrs. CCL was not notified of any of the additional cases of scabies and scabies treatment after 08/02/203. This LPA was informed on 10/18/23 that 29 more residents had been treated.
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will include a schedule of the Regional Nurse's quarterly inspection and an outline of the new scabies policy by 10/28/23.
The final policy will be be completed and submitted to CCL at kimberly.viarella@dss.ca.gov by 10/31/23
Type A
10/28/2023
Section Cited
CCR
87465(a)(9)
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CCR 87465(a)(9)
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed...(9) The licensee shall ensure that infection control practices are maintained in the facility...
The Licensee failed to comply with the above regulation:
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Licensee shall conduct training with all staff regarding new infection control policy with an emphasis on scabies prevention. This will be completed by 1122/23. By 10/28/23 Licensee shall submit the date of the all staff training to Kimberly.viarella@dss.ca.gov. Signature sheets of participants will also be included.
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Based on observations, interviews and a records review, the Licensee failed to follow their own infection control plan. Residents suspected of having scabies or showing symptoms of scabies were not separated or isolated. Deep cleanings and vacuuming were not performed. The identification of close contacts was never pursued. This poses/posed an immediate risk to residents in care.
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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: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence
(b) In addition to ...Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors ... The Licensee failed to comply with the above regulations as evidenced by:
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Licensee will increase staffing to meet the needs of the residents in care. They will supply CCL with the hours work log for the week of 7/27/23 and 10/30/23 along with the coordinating schedules showing an increase in Caregiver / Resident Assistant hours. For the immediate POC, Licensee
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Based on Interviews and observations 6/6 responsible parties stated they had found loved ones in soak adult briefs and/or pants on multiple occasions. 3/5 staff said that incontinent care is not always done as scheduled. This poses/posed an immediate health risk to residents in care during a scabies outbreak.
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shall submit the names of new hires to kimberly.viarella@dss.ca.gov by 10/28/2023.
Type A
10/28/2023
Section Cited
CCR
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87705(b)(1) (b)In addition to ..., Plan of Operation, the plan of operation shall address...with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons. The Licensee failed to comply with the above regulation as evidenced by:
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Licensee shall have all nurses receive training on skin assessment, with emphasis on scabies, to ensure that residents are sent to an MD for an evaluation as soon as scabies symptoms manifest. Licensee shall submit to CCL the date and name of the trainer for these trainings by 10/28/23
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The Licensee failed to follow its own plan of operation. and did not notify responsible parties (RP) about scabies. Based on Interviews and records review in 6/6 instances. This posed an immediate, health, safety and/or personal rights risk to those in care and did not assist in containing the spread of scabies.
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Signature sheets for participants will be submitted at a later date.
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: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87211(a)(1)(2)
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87211(a) Each licensee shall furnish to the licensing... as the Department may require: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident... (2) Occurrences, ...24 hours either by telephone... The Licensee failed to comply with the above regulation when:
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Licensee shall conduct training for all Resident Assistants and Nurses on reporting requirements. Licensee shall submit the dates of these trainings and the name of he facilitator to kimberly.viarella@ccl.ca.gov by 10/27/23. These trainings must be completed
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Based on a review of records, R5 was suspected and treated for scabies on 07/14/23. This was not reported to CCL and pose/posed an immediate risk to residents in care.
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by 11/31/23 and signature sheets will be sent to CCL.
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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: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 10
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
07/27/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20230727163804

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: 56DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
12:15 AM
MET WITH:Kent MulkeyTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff falsified resident's records.
INVESTIGATION FINDINGS:
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On 10/27/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver complaint investigation findings regarding the above allegation. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. The LPA met with Kent Mulkey and a brief interview followed.

Regarding: Staff falsified resident's records.
Based on interviews with 6 staff members and a review of records, the allegation that staff were falsifying shower logs could not be substantiated. A review of the shower logs indicated that sometimes residents refused to take a shower, which is their personal right. With regard to a lack of documenting the scabies rash in the shower logs, the individuals showering residents were not qualified to diagnose scabies. Although they should have had more thorough training on what to document and how, that was different than falsifying the documents. This LPA reviewed a sampling of the shower logs. Notations were made if a resident refused, had been showered the day prior, or if hospice had performed the task. This LPA found that 7 out of 7
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 27-AS-20230727163804
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: 10/27/2023
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shower logs were completed appropriately. The caregivers would document rashes and bruises. It was up to the nurse performing the actual skin assessments to determine if the rash might be scabies.

The standard for the preponderance of evidence has not been met and the department finds this allegation UNSUBSTANTIATED.


A property of this report was provided.

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

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 10 of 10