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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700235
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:03:21 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
10/21/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201021155857
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: 59DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Mary Keaton TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff did not properly address resident's pressure injuries
Resident sustained multiple falls while in care
Resident sustained a fracture while in care
Facility staff did not report unusual incidents to resident's authorized representatives
Questionable death




INVESTIGATION FINDINGS:
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On 06/28/2021 at 10:40 am, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with the administrator during today’s visit.

Throughout the course of this investigation, LPA conducted interviews, reviewed facility records, and inspected facility motion sensors. During an interview, witness 1 (W1) reported to have no health and safety concerns in regards to resident 1 (R1). Additionally, W1 reported facility care staff were providing pressure injury care, and had no concerns with the care that was being provided to R1 by the facility staff. Moreover, during an interview with Witness 2 (W2), W2 stated not seeing pressure injuries on R1 during her Christmas 2019 visit.

Continued..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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 3
Control Number 27-AS-20201021155857
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: 06/28/2021
NARRATIVE
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Facility fall documentation indicated the authorized representative was informed about fall incidents. Also, LPA Martinez reviewed R1's fall history and fall prevention documents. The facility implemented a fall prevention plan, which included the following: fall motion sensors, E-cord next to R1's bed and in private bathroom, hourly checks, hospital bed, and fall floor mat (breaks fall/soften fall). Based on the facility documents R1 refused to use her cane all day on 12/19/2018. The facility 9/11/2019 Bi-Monthly assessment reported R1's gait is not stable, however, R1 will not use a walker. Additionally, on 12/29/2019, R1 refused to wear a back brace.

Furthermore, LPA Martinez learned the facility documented 6 falls during the period of 2018 to 2020. The last fall documented was on 12/24/2019; R1 ambulated independently in her room and tripped over a chair. R1 was sent out to the hospital on 12/24/2019. While at the hospital, R1 was diagnosed with back pain, and a CT head scan was negative. Furthermore, 12/24/2019 hospital records documented a past vertebra L2 fracture. LPA observed the 12/06/2018 LIC 602, Physician's report for residential care facilities for the elderly (LIC 602). The LIC 602 dated 12/06/2018 stated L2 vertebra fracture. In addition, facility Nursing Evaluation/Data Collection document dated 12/6/2018 stated vertebral fracture, and the 12/29/2019 LIC 602 stated vertebra fracture.

A 12/24/2019 hospital record stated, "advanced dementia with failure to thrive". The 12/24/2019 hospital record also reported per family, R1's general health condition had been slowly declining. During the hospitalization, hospice was initiated. R1 was discharged to El Rio Memory Care on 12/29/2019. It was learned shortly after the initiation of hospice, R1 began transitioning. It was also learned R1's primary cause of death was respiratory failure secondary to senile degeneration of the brain.

Based on the investigation, El Rio Memory Care facility implemented a fall prevention plan for R1, Also R1 was diagnosed with a back fracture prior to moving into El Rio Memory Care. Moreover, facility fall incident reports indicated R1's authorized representative was informed of falls. It was also learned that R1 was receiving pressure injury care from Seva Hospice and facility staff, and there were no concerns about the care be given. In addition, there was not a preponderance of evidence to substantiate questionable death allegation due to declining health, and hospice notes indicating R1 began to transition shortly after initiation.

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

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20201021155857
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: 06/28/2021
NARRATIVE
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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. There were no deficiencies cited, and an exit interview was conducted. A copy of this report was given to Mary Keaton.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3