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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 01/04/2024
Date Signed: 01/04/2024 04:51:32 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
10/11/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231011111327
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:
01/04/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Steve SarineTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not have accurate record keeping for a resident
Staff did not address a resident's change in medical condition
Staff did not properly report an incident involving a resident
INVESTIGATION FINDINGS:
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On 1/4/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Regional Director of Operations, Steve Sarine and explained the purpose of today's visit.

During the course of the investigation LPA Jensen conducted interviews with 8 staff members and Resident 1 (R1). LPA Jensen reviewed records including but not limited R1's physician report, R1's prescriptions, R1's Needs and Service Plan, R1's Medication Administration Records (MARs), Physician Communication Forms, facility policy and procedure documents, and incident reports from June of 2023 through current. LPA Jensen also inspected R1's private room.

Allegation 1 - Staff do not have accurate record keeping for a resident
LPA Jensen reviewed the MAR for R1 for October of 2023. R1 received a prescription for a medication on 10/10/23. Continued on LIC 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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 5
Control Number 27-AS-20231011111327
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: 01/04/2024
NARRATIVE
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The prescription was written to change the strength of a medication that R1 was currently taking and the current medication was discontinued effective 10/12/23. According to the MAR, R1 did not receive any of the medication that was discontinued from 10/1/23 through 10/12/23. There are entries indicating the medication was not at the facility on 10/1/23, 10/8/23 and 10/12/23 but no explanation for the other dates. LPA Jensen also reviewed the Needs and Service Plan for R1 which was not signed or dated. As a result of the inconsistencies in the MAR and the incomplete Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Allegation 2 - Staff did not address a resident's change in medical condition
LPA Jensen reviewed R1's physician report dated 7/13/23. The physician's report states R1 is able to independently transfer to and from bed, is able to dress and groom themselves and has no bladder or bowel impairment. This contradicts the Needs and Service Plan which states R1 requires hands on help with bathing, dressing and grooming. The Needs and Service Plan also states that the resident requires a one person assist with transfer and at times 2 person assist. It further states that R1 requires AM and PM incontinence care. All sections of the Needs and Service Plan state that the Care Team will monitor for changes in condition and conduct a reappraisal as appropriate. The Needs and Service Plan depicts a significantly higher level of need for care than provided for in the physician's report and as such a new physician report's should have been obtained. Based on the comparison between the LIC 602 (Physician's Report) and the Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Allegation 3 - Staff did not properly report an incident involving a resident
LPA Jensen reviewed records showing R1 was hospitalized and being treated for a bacterial infection on or around 8/25/23. There was no evidence of an incident report being submitted to the Department for this occurrence and as such the allegation is SUBSTANTIATED.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231011111327
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: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
87506
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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident. This requirement was not met as evidenced by:
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The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.
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Based on LPA Jensen's review of the incomplete Needs and Service Plan and MAR. This poses a potential risk to the health, safety and personal rights of residents of in care.
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Type B
01/11/2024
Section Cited
CCR
87463
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Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
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The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.
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This requirement was not based on a comparison of the LIC 602 and Needs and Service Plan. This poses a potential risk to the health, safety and personal rights of 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231011111327
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: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
87211
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Reporting Requirements
A written report shall be submitted to the licensing agency... within seven days of the occurrence of ...Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:
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The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
10/11/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231011111327

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: 0DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:SteveTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow a licensed physician's orders for a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/4/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Regional Director of Operations, Steve Sarine and explained the purpose of today's visit.

During the course of the investigation LPA Jensen conducted staff and resident interviews. LPA Jensen also reviewed records including but not limited to Resident 1's physician report, physician communication forms, Medication Administration Records (MARs), Incident Reports and Needs and Service Plans. LPA Jensen reviewed documentation indicating there may have been occassions when a physician's order was not followed however LPA Jensen was unable to determine if the non-compliance was the result of inaccurate record keeping or resident refusal thus the allegation of staff did not follow a licensed physician's orders for a resident is UNSUBSTANTIATED. A finding of unsubstantriated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted, and a copy of the report was given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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 5