507000306-6-22-2023-27-AS-KHOS-CTFLDW-20230705084038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507000306
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:41:01 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
02/22/2023 and conducted by Evaluator Jason Lund

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230222154658

FACILITY NAME:	COVENANT CARE-TURLOCK RESIDENTIAL		FACILITY NUMBER:	507000306
ADMINISTRATOR:	RUTH VILLARREAL		FACILITY TYPE:	740
ADDRESS:	1101 E. TUOLUMNE ROAD		TELEPHONE:	(209) 667-8409
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95380
CAPACITY:	49	CENSUS: 39	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Jennifer Warkentin		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not prevent residents from smoking cigarettes in the facility

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.
Staff do not prevent residents from smoking cigarettes in the facility - Based on LPA Lund interviews with staff, residents, and observation. LPA Lund and Administrator Jennifer Warkentin smelled cigarette smoke coming from the exit door where residents were smoking coming into the facility near rooms. Rooms 111 through 118 did have the smell of cigarette smoke.
Based on LPA observations, and interviews, 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.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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 5

Control Number 27-AS-20230222154658

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: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2023 Section Cited CCR 87468(a)	1 2 3 4 5 6 7	87468 (a) Personal Rights. Residents in residential facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.	1 2 3 4 5 6 7	Administrator will arrange will with management to try a find smocking area.
	8 9 10 11 12 13 14	The following requirement has not been met as evidenced by: LPA Lund and Administrator Jennifer Warkentin smeeled smoke it the facility.Poses an immediate health, safety, or personal rights risk to residents 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
02/22/2023 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20230222154658

FACILITY NAME:	COVENANT CARE-TURLOCK RESIDENTIAL		FACILITY NUMBER:	507000306
ADMINISTRATOR:	RUTH VILLARREAL		FACILITY TYPE:	740
ADDRESS:	1101 E. TUOLUMNE ROAD		TELEPHONE:	(209) 667-8409
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95380
CAPACITY:	49	CENSUS: 39	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Jennifer Warkentin		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff gave a resident the wrong medication
Staff do not serve nutritious meals to residents causing illness
Facility carpet is dirty/stained
Facility furniture is dirty/stained
Residents are unable to see through sliding glass door
Facility fencing in disrepair

INVESTIGATION FINDINGS:

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Staff gave a resident the wrong medication- Based on LPA Lund interviews with staff, residents, and record review. The facility has not reported a medication error since 2022. LPA Lund reviewed four residents Medication Administration Record Sheet and found no errors. LPA Lund interviewed residents in care and no reports of wrong medication was stated. The Meds Tech are trained on how to give the medications and to report to management if a medication error has happened.

Based on facility records review, interviews with staff, and residents the information provided, it was unclear if staff are mismanaging residents medication therefore the allegation was deemed UNSUBSTANTIATED.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20230222154658

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: 06/22/2023

NARRATIVE

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Based on facility records review, interviews with staff, and residents the information provided, it was unclear if staff are mismanaging residents medication therefore the allegation was deemed UNSUBSTANTIATED.
Staff do not serve nutritious meals to residents causing illness - Based on records review, interviewed with staff and residents in care. Residents are given nutritious meals and meals to fit the residents needs. Residents are given the option to eat what is on the menu are request something different if they do not like the menu option.
Based on facility records review, interviews with staff, and residents the information provided, it was unclear if staff do not serve nutritious meals to residents causing illness therefore the allegation was deemed UNSUBSTANTIATED.
Facility carpet is dirty/stained- Based on records review, interviews with staff, residents in care and observation. The facility replaced carpet in the main walk in the facility and not in the rooms of the facility. The facility rooms continued to get clean through housekeeping, maintenance and a private company who come out to clean when needed. LPA observed some stains on the carpet but no smell.
Based on facility records review, interviews with staff, residents and observation the information provided, it was unclear if facility carpet is dirty/stained therefore the allegation was deemed UNSUBSTANTIATED.
Facility furniture is dirty/stained- Based on records review, interviewed with staff and residents in care and observation. The facility replaced some of furniture in the lobby and in front of the facility. The facility rooms continued to get clean through housekeeping and maintenance. LPA observed the furniture to clean and in good repair.
Based on facility records review, interviews with staff, residents and observation the information provided, it was unclear if facility furniture is dirty/stained therefore the allegation was deemed UNSUBSTANTIATED.
Residents are unable to see through sliding glass door - Based on records review, interviewed with staff and residents in care and observation. The facility has replaced some of sliding glass doors and continue to replace, but the sliding glass doors are not unsafe due to the oxidation. LPA observed the sliding glass doors to be safe for residents in care.
Based on facility records review, interviews with staff, residents and observation the information provided, it was unclear if residents are unable to see through sliding glass door therefore the allegation was deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20230222154658

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: 06/22/2023

NARRATIVE

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Facility fencing in disrepair- Based on interviews with staff and residents in care and observation. LPA Lund observed that fencing are not unsafe residents in care.
Based on interviews with staff, residents and observation the information provided, it was unclear if Facility fencing in disrepair therefore the allegation was deemed UNSUBSTANTIATED.
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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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