502700616-8-17-2020-27-AS-LKIG-BSU5RW-20200825201150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700616
Report Date: 08/17/2020
Date Signed: 08/17/2020 09:14:18 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
03/19/2020 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200319172452

FACILITY NAME:	GOLDEN AGE LIVING TURLOCK		FACILITY NUMBER:	502700616
ADMINISTRATOR:	JACOPETTI, JOSHUA C.		FACILITY TYPE:	740
ADDRESS:	1259 JOETT DRIVE		TELEPHONE:	(209) 417-2742
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95380
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2020
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Telephone Call - Precaution Due To COVID -19/Administrator Kelsey Ramos		TIME COMPLETED:	08:50 AM

ALLEGATION(S):

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Facility failed to report incident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility via telephone to provide complaint investigation finding via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed with Administrator (AD) Kelsy Ramos the purpose of the call which was to deliver finding for the allegation that Facility failed to report incident.
The initial 10-Day visit was conducted on March 24, 2020. LPA Wallace reviewed R1's Admission’s Agreement, Physician's Report, Needs and Services Plan, Medical Records, and Incident Report requested by Administrator at facility. Resident (R1) sustained an injury as a result from R1 getting out of wheelchair and falling onto the bedroom floor.
Right after the fall of R1, staff called 911, Hospice Care, Administrator, and wife of R1. R1 was transported to hospital by ambulance and admitted into the hospital on March 6, 2020. It was determined after x-rays were taken that R1 had a left broken femur, fractured in several places.
Facility reported to Community Care Licensing with a detailed Incident Report according to our Regulations. Based on the documentation there was not a preponderance of evidence that the event occurred, therefore the allegation was deemed UNFOUNDED. This agency has investigated the allegation noted above. The complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department therefore has dismissed the allegation.
An exit interview was conducted with AD Ramos. A copy of this report was provided via email with read receipt along with a Confidential Names list, and Appeal Rights. AD Ramos will sign and send back to LPA via email.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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