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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507000306
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:38:47 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
08/09/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220809140921
FACILITY NAME:COVENANT CARE-TURLOCK RESIDENTIALFACILITY NUMBER:
507000306
ADMINISTRATOR:RUTH VILLARREALFACILITY TYPE:
740
ADDRESS:1101 E. TUOLUMNE ROADTELEPHONE:
(209) 667-8409
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:49CENSUS: 42DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Jennifer Warkentin TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not in good repair

Resident's room is malodorous
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jason Lund arrived at the above facility to complete a complaint investigation. LPA Lund met with Administrator Jennifer Warkentin and explained the reason for the visit.

Facility is not in good repair- Based on LPA Lund observations, record review, and interviews, with staff and residents. LPA Lund did observe room 106 needing a new carpet. The bathroom needed updating prior to letting new Residents (R1) & (R2) moving into the room. R1 & R2 lived in the room for approximately two months before the repairs were made to the room.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220809140921
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: COVENANT CARE-TURLOCK RESIDENTIAL
FACILITY NUMBER: 507000306
VISIT DATE: 10/27/2022
NARRATIVE
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Resident's room is malodorous- Based on LPA Lund interviews with staff, residents, and record review. Room 106 needing a new carpet and the bathroom needed updating prior to letting new Residents (R1) & (R2) moving into the room. R1 & R2 lived in the room for approximately two months before the repairs were made to the room.


Based on LPA observations, record review, and interviews, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Jennifer Warkentin. A copy of this report was left and appeal rights were given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220809140921
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: COVENANT CARE-TURLOCK RESIDENTIAL
FACILITY NUMBER: 507000306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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Administraor will observe other rooms that may need to be updated.
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This requirement was not met as evidenced by the: LPA Lund observed that the carpets need to be replaced. This poses a potential health, safety or Personal Rights risk to resident in care.
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Type B
11/10/2022
Section Cited
CCR
87303(a)(1)
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Maintenance and Operation-
Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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Administraor will observe other rooms that may need to be updated.
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This requirement was not met as evidenced by the: Staff and residents interviewed stated the room 106 was malodoros. This poses a potential health, safety or Personal Rights risk to resident 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: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
08/09/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220809140921

FACILITY NAME:COVENANT CARE-TURLOCK RESIDENTIALFACILITY NUMBER:
507000306
ADMINISTRATOR:RUTH VILLARREALFACILITY TYPE:
740
ADDRESS:1101 E. TUOLUMNE ROADTELEPHONE:
(209) 667-8409
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY:49CENSUS: 42DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Jennifer Warkentin TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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Staff are mismanaging residents medication- Based on record review, interviewed with staff and residents. Resident (R1) had a PRN that went from two tabs to one tab per Medication Administration Records (MARS). The medication was the same dosage for the PRN.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4