502700235-9-19-2024-27-AS-MJEN-D9A26C-20240919170653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:06:59 PM

Document Has Been Signed on 09/19/2024 05:06 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 COMMUNITY		FACILITY NUMBER:	502700235
ADMINISTRATOR:	THERESA PETTAPIECE		FACILITY TYPE:	740
ADDRESS:	2828 HEALTHCARE WAY		TELEPHONE:	(209) 543-3805
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	72	CENSUS:	DATE:	09/19/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Theresa Pettapiece		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Maja Jensen arrived on 9/19/24 for an unannounced visit to follow up on a complaint investigation received on November 22, 2022. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of the visit.

On March 14, 2023, the Department concluded a complaint investigation which alleged that the facility did not reposition a resident (R1) which resulted in a pressure wound, facility failed to seek timely medical care for a pressure wound, and facility staff neglected a resident, resulting in an injury. Allegations that the facility did not reposition a resident, resulting in a pressure wound, and that the facility failed to seek timely medical care for a pressure wound were substantiated.

The licensee was cited for California Code of Regulations (CCR) CCR Sections 87465(a)(1) and 87465(a)(2).

At the time of the complaint visit on March 14, 2023, two immediate civil penalties of $500 totaling $1000 were issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to observe R1’s change in condition and failing to seek medical treatment on or about November 13, 2022, to November 17, 2022, when R1 was hospitalized for a stage 4 pressure injury and a diagnosis of sepsis.

At the time of a complaint investigation visit on March 14, 2023, two immediate civil penalties, each in the amount of $500, were assessed, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 09/19/2024

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Today, 09/19/2024, the Department will be assessing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since immediate civil penalties totaling $1,000 were previously assessed on March 14, 2023, the amount of the civil penalty issued today will be $9,000.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Theresa Pettapiece and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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