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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 10/04/2021
Date Signed: 10/04/2021 09:42:46 PM

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: 67DATE:
10/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carlin RobertsonTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced at the facility for a case management visit related to two incidents reported to licensing. The first incident was a fall that occurred on 09/16/2021. The second incident was an AWOL reported 9/21/21. LPA met with Business Office Manager Carlin Robertson and explained the purpose of todays visit. The facility has 67 resident at this time.

LPA observed the egress door, and spoke with Carlin about the AWOL incident. The egress door alarm was not heard because of the pull chord alarms going off at the same time sounded over the egress alarm door. The normal front desk staff was assisting with coffee at the time resident left the facility and therefore no one witnessed resident walking out.

LPA spoke with Carlin about the recent fall incident and even though she knew a fall took place she was not aware of the details. The incident report stated resident fell and was in her own urine and blood until staff discovered her. The incident report stated that nurse did not know how long resident was there because she missed morning rounds because it was so busy.

The following deficiencies are being cited during today's inspection per California Code of Regulations, Title 22.

An exit interview was conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited

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Care of persons with dimentia 87705K(8)Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement has not been met as evidenced by:
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Facility is aware of residents behaviors but no staff was at entrance. This poses an immediate health and safety 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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2021
LIC809 (FAS) - (06/04)
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