502700869-4-5-2023-27-AS-KHOS-CR2MXH-20230419095955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700869
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:49:55 PM

Substantiated

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
01/27/2023 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20230127114428

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:	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Excutive Director Alma Whitted		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained a serious injury due to inadequate staff supervision

INVESTIGATION FINDINGS:

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On 4/5/2023 Licensing Program Analyst (LPA) Jason Lund arrived unannounced to deliver a complaint investigation finding. LPA Lund met with Excutive Director Alma Whitted and explained the reason for the visit.

Resident sustained a serious injury due to inadequate staff supervision: Resident (R1) eloped from the facility and sustained serious injuries. Based on a review of video footage, on 01/21/2023 at approximately 3:46 pm, R1 exited the facility. Staff (S1) heard the door alarm and turned it off without confirming whether a resident had exited the building. At approximately 3: 53 pm, R1 exited the courtyard gate and eloped from the facility. Staff (S2) stated that S2 heard the gate alarm and responded but did not see anyone outside. At approximately 6:30 pm, Staff (S3) was informed R1 was in the hospital and that is when facility staff realized R1 had eloped.

Substantiated

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: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20230127114428

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: 04/05/2023

NARRATIVE

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According to facility records, R1 was supposed to have hourly status checks, but R1 had been gone for almost three hours before caregivers realized R1 had eloped. According to medical records, R1 sustained a basilar skull fracture, distal left radius/ulna fracture, LI compression fracture, scalp laceration requiring staples and a subdural hematoma. S1 and S2 both admitted that they failed to follow elopement procedures.

As a result of this investigation, LPA Lund finds allegation to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid due to the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations.

Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued. The circumstances of this complaint are being evaluated for enhanced civil penalties.

The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of the resident having serious bodily injury while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Exit interview conducted and report provided. Appeals rights printed

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230127114428

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/06/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,...(4)To care, supervision, and services that meet their individual needs....	1 2 3 4 5 6 7	Excutive Director Alma Whitted will have training with staff and email LPA Jason Lund copy of training.
	8 9 10 11 12 13 14	This was not met as evidenced by:Based on investigation R1 eloped from the facility and sustained serious injuries, the licensee did not ensure resident supervison while in care at the facility.This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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