502700235-4-16-2021-27-AS-KHOS-C2ALWE-20210421090701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 04/16/2021
Date Signed: 04/16/2021 10:40:11 AM

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
09/30/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200930112221

FACILITY NAME:	EL RIO MEMORY CARE COMMUNITY		FACILITY NUMBER:	502700235
ADMINISTRATOR:	KEATON, MARY		FACILITY TYPE:	740
ADDRESS:	2828 HEALTHCARE WAY		TELEPHONE:	(209) 543-3805
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	72	CENSUS: 49	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mary Keaton		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident’s medical device was placed incorrectly.
Resident's basic needs were not being met.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 27-AS-20200930112221

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: 04/16/2021

NARRATIVE

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Moreover, on 03/23/2020, the facility received a prescription order for Tea Tree oil. On 05/29/2020 via email, facility staff requested the Tree Tea oil be delivered to the facility by the responsible party. The 05/29/2020 email correspondence indicates the facility was informed that the Tree Tea oil was delivered. Moreover, facility staff replied to 05/29/2020 email, and facility staff acknowledged that the Tea Tree oil was in the facility on 05/29/2020.

Based on the medication administration record (MAR) and email correspondence review, Tea Tree oil was prescribed to R1. Additionally, Tea Tree oil was delivered to the facility by the responsible party. However, the Tea Tree oil was not being administered, and R1's medication care needs were not being met. On R1's admission agreement, section II. Personal Assistance and Care states " in accordance with your plan of care and applicable California law, will provide you assistance, as needed, with activities of daily living, such as bathing, dressing, ambulating, and assistance with medication. The facility did not ensure to provide basic care services, such as assistance with medication.

As a result of this investigation, the Department finds these allegations to be substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20200930112221

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: 04/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/19/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)..."Care and supervision" means the facility assumes responsibility for,... ongoing assistance with activities of daily living ....This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator agrees to conduct an in-service on how to complete an medication administration record (MAR;) and review medication intake from an outside source procedure; and on how to assist residents with prosthetic devices. The administrator agrees to email training materials and log in sheet by 04/22/2021.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure R1's basic service/ medication needs were being met. Tea Tree oil was not being administered as prescribed. This posed an immediate health and safety risk to resident 1.	8 9 10 11 12 13 14	The administrator agrees to email in-service agenda by 04/19/2021.
Type B 04/19/2021 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use...	1 2 3 4 5 6 7	The administrator agrees to conduct an in-service on how to complete an medication administration record (MAR;) and review medication intake from an outside source procedure; and on how to assist residents with prosthetic devices. The administrator agrees to email training materials and log in sheet by 04/22/2021.
	8 9 10 11 12 13 14	of these devices, and shall assist such persons with their utilization as needed. This requirement is not met as evidenced by:Based on interviews and records review, the licensee did not ensure R1's hearing aids were being inserted in the correct ears. This posed a potential health and safety risk to resident 1.	8 9 10 11 12 13 14	The administrator agrees to email in-service agenda by 04/19/2021.

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
09/30/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200930112221

FACILITY NAME:	EL RIO MEMORY CARE COMMUNITY		FACILITY NUMBER:	502700235
ADMINISTRATOR:	KEATON, MARY		FACILITY TYPE:	740
ADDRESS:	2828 HEALTHCARE WAY		TELEPHONE:	(209) 543-3805
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	72	CENSUS: 49	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mary Keaton		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not ensure resident was wearing shoes.
Staff did not properly maintain resident’s file.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings 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 allegations with Mary Keaton.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. Witness 1 (W1) reported resident 1 (R1) did not have issues with wearing or keeping shoes on. Moreover, LPA Martinez reviewed R1’s facility file. LPA Martinez observed medical insurance cards, contact sheet, and care plan, and facility notes in R1's facility file. Furthermore, R1's admission agreement does not state that the facility shall provide a copy of R1's medical insurance card to medical providers.

This agency has investigated the complaints alleging staff did not ensure resident was wearing shoes and staff did not properly maintain resident’s file. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. 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.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 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.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
09/30/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200930112221

FACILITY NAME:	EL RIO MEMORY CARE COMMUNITY		FACILITY NUMBER:	502700235
ADMINISTRATOR:	KEATON, MARY		FACILITY TYPE:	740
ADDRESS:	2828 HEALTHCARE WAY		TELEPHONE:	(209) 543-3805
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	72	CENSUS: 49	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mary Keaton		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident’s hygiene needs are not being met.
Towels are not available to resident’s.
Resident developed a nail fungus while in care.
Staff did not meet resident’s grooming needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings 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 allegations with Mary Keaton.

Throughout the course of the investigation, LPA Martinez conducted a virtual visit; conducted interviews; and reviewed facility documents. LPA Martinez toured the facility virtually and observed residents to be clean and well groomed. LPA Martinez also observed an adequate supply of bathing-towels. Furthermore, bathing-towels are provided to residents during their scheduled shower due to being a part of the facility's fall prevention plan. Hand towels are stored in residents' personal bathrooms. Moreover, based on resident's 1 (R1) medical file review and interviews, it was learned that R1's thumb nail was being treated with Apple Vinegar before moving in. As a result, It is unknown when R1 developed nail fungus on her thumb. Additionally, based on a medical file review and interviews there was not a preponderance of evidence to prove R1's hygiene needs were not being met by facility staff.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 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.

LIC9099 (FAS) - (06/04)

Page: 5 of 5