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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 12/05/2024
Date Signed: 12/05/2024 04:05:58 PM

Document Has Been Signed on 12/05/2024 04:05 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/
DIRECTOR:
THERESA PETTAPIECEFACILITY TYPE:
740
ADDRESS:2828 HEALTHCARE WAYTELEPHONE:
(209) 543-3805
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 72TOTAL ENROLLED CHILDREN: 0CENSUS: 53DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Theresa PettapieceTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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LPA Jensen arrived at facility unannounced to conduct a case management in relation to multiple death reports received. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit.

LPA Jensen received multiple death reports for residents on hospice between the period of 11/2/24 and 11/9/24.

LPA Jensen reviewed the Certificate of Death with physician attestation for resident 1 (R1) and immediate cause of death is listed as senile degeneration of the brain.

LPA Jensen reviewed the Certificate of Death with physician attestation for resident 2 (R2) and immediate cause of death is listed as senile degeneration of the brain. The incident report or LIC 624A for R2 was sent to the Department on 11/7/24 and lists the date of death as 10/2/24. The death certificate lists the date of death as 11/2/24. There appears to have been a misprint on the LIC 624A sent to the Department and the reporting was in fact done in a timely manner.

LPA Jensen reviewed the Certificate of Death with physician attestation for resident 3 (R3) and immediate cause of death is listed as Alzheimer's disease.

LPA Jensen reviewed the Hospice Death Report Summary for R4 which lists the hospice diagnosis as senile degeneration of the brain and lists physical findings as no pulse or respirations, skin pale and cool.

No deficiencies were observed. The reporting appears to be compliant. An exit interview was conducted and a copy of this report was provided.
Lisa RiosTELEPHONE: (916) 969-9685
Maja JensenTELEPHONE: (916) 639-5584
DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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