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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 03/14/2023
Date Signed: 03/29/2023 02:55:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Jason Lund
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221122165627
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: 58DATE:
03/14/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Mary KeatonTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not reposition resident resulting in pressure wound

Facility failed to seek timely medical care for pressure wound.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit on 3/29/2023 to amend the complaint and met with Administrator Mary Keaton and explained the reason for the visit.
LPA Lund met with Administrator Carlin Robertson and explained the purpose of today's visit.Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit at the facility to
Facility failed to seek timely medical care for the Resident’s pressure wound- On November 9th, 2022, resident (R1) was observed to have a lump on the right buttock that was hard, raw, extremely red and warm to touch. A Medical Physician was notified, and medication was prescribed. On November 13, 2022 the lump ruptured got grey and was infected. R1 complained that the wound was hurting, wasn’t feeling well and felt cold. On November 14th, 2022, R1 ate a small amount of breakfast and did not feel well. R1 did not want to eat dinner and went to bed early.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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 4
Control Number 27-AS-20221122165627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
VISIT DATE: 03/14/2023
NARRATIVE
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Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit on 3/29/2023 to amend the complaint and met with Administrator Mary Keaton and explained the reason for the visit.
The wound opened up and began to drain that night. On November 16, 2022 R1 was in a lot of pain and did not eat breakfast. On November 17th, 2022, R1 was sent to the hospital after R1’s wound was draining and had a foul odor. The hospital diagnosed R1 with a stage 4 wound, underwent debridement and suffered from sepsis. R1 was discharged from the hospital on hospice and passed away on December 1, 2022. The facility staff did not provide an explanation of why R1 was not provided timely medical assistance.
Facility staff neglected Resident’s resulting in injury- Staff were aware that Resident (R1) had a wound and communicated with R1’s Physician regarding the wound; however, the wound continued to progress. As the wound worsen, R1 showed other symptoms such as not eating, no signs of progress and R1 continued to be lethargic which was a considered a change of condition. Staff failed to notice those changes and failed to seek medical attention resulting in R1 being diagnosed with stage #4 wound and sepsis. R1 was discharged from hospital on hospice and passed away on December 1, 2022.
As a result of this investigation, LPA Lund finds allegations to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations.
Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued. The circumstances of this complaint are being evaluated for enhanced civil penalties.
The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of the resident sustaining a pressure wound (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.
Exit Interview give and report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20221122165627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EL RIO MEMORY CARE COMMUNITY
FACILITY NUMBER: 502700235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Administrator will look over the regulation and have training with staff and email LPA Lund proof of training.
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On 11/9/2022 Resident (R1) was observed to have a lump on right buttock. On 11/17/2022, R1 was sent to the hospital. The facility did not provide an explanation of why R1 was not provided timely medical assistance. This poses an immediate health, safety and personal rights risk to residents in care.
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Type A
03/15/2023
Section Cited
CCR
87465(a)(2)
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The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need….
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Administrator will look over the regulation and have training with staff and email LPA Lund proof of training.
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This requirement was not met as evidenced by: Staff failed to notice Resident (R1) changes and failed to seek medical attention resulting in R1 being diagnosed with stage #4 wound and sepsis. This poses an immediate health, safety and personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Jason Lund
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221122165627

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: 58DATE:
03/14/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Mary Keaton TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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3
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5
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7
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9
Facility staff neglected resident resulting in injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit on 3/29/2023 to amend the complaint and met with Administrator Mary Keaton and explained the reason for the visit.
Facility staff neglected resident resulting in injury-
Resident (R1) was wheelchair bound but was able to get around independently. The staff that were interviewed reported that they re-positioned R1’s bed or the wheelchair per protocol every, one to two hours. However, there were no logs or documentation that indicated R1 was rotated. Staff reported that at times after R1 had been re-positioned, R1 would revert to R1’s prior position. This is reflected by the medical records that indicate that R1 was difficult to turn and reposition. R1 laid on one side curled up and was combative when R1 was repositioned.
As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator Carlin Robertson and a copy of report and a copy of the appeal rights was left.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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 4