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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 04/16/2021
Date Signed: 04/16/2021 10:27:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
502700235
ADMINISTRATOR:KEATON, MARYFACILITY TYPE:
740
ADDRESS:2828 HEALTHCARE WAYTELEPHONE:
(209) 543-3805
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:72CENSUS: 49DATE:
04/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary Keaton TIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to conduct a case management on 04/16/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the case management with Mary Keaton

The purpose of the case management visit is to follow up on a medication deficiency learned throughout a complaint investigation (27-AS-20200930112221). The following medication deficiency was discovered:

March 2020 Medication Administration Record (MAR) indicates Tea Tree oil was added to R1's routine medication. However, March, April, and May MAR sheets for Tea tree oil are blank. June’s 2020 MAR for Tea Tree oil is incomplete; June 1st, 2nd, 18th, and 19th entries are blank. The other June entries are initialed and circled. Based on the medication file review, the licensee did not ensure to maintain R1's MAR sheets and did not maintain oversight on the Tea Tree oil medication while in the facility.

As a result, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted with Mary Keaton via telephone, and a copy of this report was provided to Mary Keaton via email, and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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
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: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2021
Section Cited

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87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

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(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure R1's Tea Tree Oil MAR sheets were being maintained. This posed a potential health and safety risk to resident 1.
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The administrator agrees to email in-service agenda by 04/19/2021.

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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2021
LIC809 (FAS) - (06/04)
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