502700869-1-12-2023-27-AS-KHOS-CNNMFN-20230202083437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:28:48 PM

Unsubstantiated

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
08/24/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20220824135553

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: 42	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Resident Care Coordinator Andrea Eldridge		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff retaining resident who requires a higher level of care

Staff did not seek medical attention for resident in a timely manner

Staff are not following protocals to prevent the spread of illness

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation. LPA Lund was met with Resident Care Coordinator Andrea Eldridge and explained the reason for the visit.

Staff retaining resident who requires a higher level of care- Based on facility records reviewed, interviews with staff and witness. Facility records (Unusual Incident/Injury Report LIC 624) dated 2/26/2022 the facility reported that Resident (R1) was sent to the Emergency Room (ER) for evaluation and was discharged on 3/1/2022 with a diagnosis of cellulitis’s, dermatitis with skin changes. When R1 was discharged and returned back to the facility with Lifeguard Home Health services. The services included a Registered Nurse and Physical Therapist to help R1 twice a week. R1 was with Lifeguard Home Health from 3/1/2022 through 9/27/2022 and Lifeguard Hospice from 9/27/2022 through 10/4/2022 when R1 was discharged from the facility. R1’s Power of Attorney (POA), Resident Care Coordinator Andrea Eldridge and Lifeguard Guard Hospice agreed that R1 needing higher level of care.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20220824135553

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: 01/12/2023

NARRATIVE

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Based on records review and interviews the facility had in home support services from 3/1/2022 through 9/27/2022 and hospice services from 9/27/2022 through 10/4/2022. On the information provided, therefore the allegation was deemed UNSUBSTANTIATED.
Staff did not seek medical attention for resident in a timely manner- Based on facility records reviewed and interviews with staff and witness. Facility incidents reports (Unusual Incident/Injury Reports LIC624’s) dated 2/26/2022, 7/29/2022, 8/16/2022 and 10/4/2022 reported that Resident (R1) went to the Emergency room for different diagnosis. R1 was with Lifeguard Home Health from 3/1/2022 through 9/27/2022 and Lifeguard Hospice from 9/27/2022 through 10/4/2022 when R1 was discharged from the facility. R1’s Power of Attorney (POA), Resident Care Coordinator Andrea Eldridge and Lifeguard Guard Hospice agreed that R1 needing higher level of care.
Based on records review and interviews the facility did seek medical attention for R1 and had in home support services from 3/1/2022 through 9/27/2022 and hospice from 9/27/2022 through 10/4/2022. On the information provided, therefore the allegation was deemed UNSUBSTANTIATED.
Staff are not following protocols to prevent the spread of illness- Based on records review and interviews with staff. Facility records (Unusual Incident/Injury Report LIC 624) dated 7/29/2022 the facility reported that Resident (R1) was sent to the Emergency room for evaluation and R1 was diagnosed with an autoimmune disorder that was not contagious to staff or residents in care. R1 would scratch and make the diagnosis worse and staff and in-home support would where PPE attire to treat R1. The facility has an Infection Control 01 – Infection Control Policy Dated: 05-05-2022.
Based on records review and interviews the facility didn’t have a resident who had a diagnosis with a contagious diagnosis on the information provided, therefore the allegation was deemed UNSUBSTANTIATED.
The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted with Resident Care Coordinator Andrea Eldridge and copy of the report was left

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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