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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:50:38 PM


Document Has Been Signed on 12/05/2023 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: 177DATE:
12/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rikki Perezchica, AdministratorTIME COMPLETED:
04:15 PM
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On 12/04/2023, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to this facility to conduct a case management visit. LPA met with Administrator, Rikki Perezchica and explained the purpose of the visit. Current Census was 177.

The purpose of this visit was to follow up on a Medication Error incident Report on 10/26/23 and several reports of falls that occurred between 11/04/23 and 11/07/23. LPA Campbell interviewed the Administrator and Medical Technician LPA Campbell conducted interviews and reviewed facility documentation.

The Unusual Incident Report received by the department on 10/26/23 states that a resident received a medication in error. The resident was later admitted to the hospital that same night due to severe constipation. Though it is unknown if this was due to the medication error. LPA Campbell reviewed the residents MAR for the date of the incident. It was learned that the Medication Technician admitted that the error was due to her inattention. An internal investigation was conducted and the MT involved underwent procedural retraining that included the 6 Rights of Medication, shadowing and a Medication Management Competency Quiz. The MT has not experienced further medication errors per the administrator.

The Unusual Incident Report received by the department between 11/04/23 and 11/07/23 involved several resident falls. LPA Campbell reviewed the incident reports, progress notes and service plans for the residents involved. Of the falls recorded, there was no common denominator. Residents fell due to a refusal to follow their care, because they were in need of a change in their care plan or because the resident experienced a one time fall after tripping. It was learned that the facility provided all residents a fall risk re-evaluation according to the facility Fall Policy and adjustments in their care plans were made as needed.

Based on the information gathered during today's visit. No deficiencies are being cited. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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