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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 12/04/2023
Date Signed: 12/04/2023 05:11:23 PM


Document Has Been Signed on 12/04/2023 05:11 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: 58DATE:
12/04/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kent MulkeyTIME COMPLETED:
05:30 PM
NARRATIVE
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On 12/4/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Administrator Kent Mulkey and explained the purpose of today's visit.

On 8/22/23 a Non-Compliance Conference was held for the following areas of concern:

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

LPA Jensen reviewed incident reports and verified they are being sent timely. LPA Jensen observed a resident that sustained a recent injury related to a fall and reviewed the incident report for the fall on 11/26/23 which was faxed to the Department on 12/1/23 and was sent timely. LPA Jensen has also received phone calls and incident reports related to resident on resident altercations within the past week. LPA Jensen reviewed pest control documents and verified that the facility has contracted with Clark Pest Control with the last service date being 11/10/23.

LPA Jensen reviewed 4 resident files and determined that 2 of 4 resident files contained physician reports that were over 12 months old. 4 of 4 needs and service plans were determined to be current.

Deficiencies are being cited form the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies mat result in the assessment of civil penalties. An exit interview was conducted and a copy of this report 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: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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 2


Document Has Been Signed on 12/04/2023 05:11 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: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia
Each resident with dementia shall have an annual medical assessment as specified in Section 87458...This requirement was not met based on:
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The Licensee agrees to update all LIC 602's that are over 12 months old and will email an attestation to LPA Jensen that this has been completed by the POC due date.
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LPA Jensen's record review of 2 of 4 resident files which did not contain a current LIC 602. 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: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2