502700869-9-2-2021-27-AS-SDOB-C6WN44-20210916100720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:36:06 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
07/27/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210727102217

FACILITY NAME:	ORANGEBURG MANOR		FACILITY NUMBER:	502700869
ADMINISTRATOR:	ARBIOS, MARIE		FACILITY TYPE:	740
ADDRESS:	1248 NELSON AVENUE		TELEPHONE:	(209) 527-2222
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	90	CENSUS: 24	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marie Arbios, Administrator		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Resident sustained a fracture while in care.
Facility staff did not seek medical attention in a timely manner.
Facility staff did not accept resident back from a hospital stay.
Facility staff did not allow resident to have visitors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to ORANGEBURG MANOR to deliver the finding of the above allegations. LPA met Administrator Marie Arbios.

The initial 10 day Visit was conducted on 7/28/2021.

Through the course of the investigation, LPA conducted interviews, reviewed staff/ resident records and facility records. It was alleged that the resident sustained a fracture while in care, the facility staff did not seek medical attention in a timely manner, the facility staff did not accept resident back from a hospital stay, and the facility staff did not allow resident to have visitors.
(9099 CONT. >>>>>>>>>>>)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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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Control Number 27-AS-20210727102217

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: ORANGEBURG MANOR	FACILITY NUMBER: 502700869
	VISIT DATE: 09/02/2021

NARRATIVE

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(9099 CONT. >>>>>>>>>>>)

Records revealed resident complained of shortness of breath and dizziness and was taken to the Emergency Room the same day. Records show normal range of mobility at time of hospital admittance. Medical records showed resident did have a contusion, which the physician noted could have been caused from a mechanical fall while ambulating with walker. Interviews conducted revealed resident made no complaints of falling.
Upon discharge, facility was notified of changes to resident’s current health conditions. Records revealed facility requested physicians orders in order to accept the resident. Once received, facility contacted responsible party informing resident approval to return. At that time, responsible party moved the resident into an alternative location.
Interviews conducted confirm visitors were allowed in designated area. Due to Covid, visitors could have been denied visitation as guidance from the Governor may have instructed facilities to refrain from allowing visitors to enter the facilities.
Based on information provided through interviews and documentation, it was unclear the resident sustained a fracture while in care, the facility staff did not seek medical attention in a timely manner, the facility staff did not accept resident back from a hospital stay, and the facility staff did not allow resident to have visitors. Therefore, the allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
No deficiencies cited. An exit interview was conducted with Administrator Marie Arbios. A copy of this report will be provided to the AD via email.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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