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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004929
Report Date: 03/12/2024
Date Signed: 04/04/2024 10:53:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231213133955
FACILITY NAME:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 2DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cecelia CandidoTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care
INVESTIGATION FINDINGS:
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On 3/12/24 Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPAs Jensen and Lewis met with Administrator Cecelia Candido and explained the purpose of today's visit.

During the course of the investigation LPA Jensen conducted interviews with 2 residents, a family member of a resident, a home health aide, a hospital social worker, 3 facility staff and the Ombudsman. LPA Jensen also reviewed records pertaining to Resident 1 (R1) that includes medical records, hospital letter of agreement records, needs and service plans, facility incontinence care plans, facility wound care plans and wound photos. The Administrator provided photos of a wound to R1's posterior dated 9/25/23 and 9/28/23. Based on the photos provided by the Administrator the resident had a significant wound while in facility care. The Administrator confirmed that she took the photos herself and that R1 was receiving wound care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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-20231213133955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
VISIT DATE: 03/12/2024
NARRATIVE
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During an office meeting on 2/13/24 the Administrator also confirmed that the resident was in facility care with the wound as shown in the photos from 9/25/23 and 9/28/23. There was no documentation to support the wound condition was pre-existing when the resident entered the facility therefore the allegation of "resident developed a pressure injury while in care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited pursuant to the California Code of Regulations, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20231213133955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/13/2024
Section Cited
CCR
87464(f)(1)
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Basic Services
Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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R1 no longer resides at the facility. The facility has conducted additional training on wound care and personal rights. The facility has also increased resident observation and documentation. No further plan of correction is required.
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Based on interviews conducted, facility records, medical records and photographs taken by the Administrator, R1 did not receive the care and supervision needed to prevent a wound which endangered their physical health. This poses an immediate risk to the health, safety and personal rights of residents 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231213133955

FACILITY NAME:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 2DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cecelia CandidoTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are not meeting resident's incontinence needs
INVESTIGATION FINDINGS:
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On 3/12/24 Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPAs Jensen and Lewis met with Administrator Cecelia Candido and explained the purpose of today's visit.

During the course of the investigation interviews were conducted with the Administrator, a facility care provider, a home health aid, and a resident's responsible party. LPA Jensen also reviewed the facility incontinence care plan. On 3 separate occasions LPA Jensen visited the facility and observed the facility to be free of odor and observed resident incontinence care needs to be met. Based on interviews conducted, records reviewed and LPA Jensen's facility observations the allegation of "Staff are not meeting resident's incontinence needs" is UNSUBSTANTIATED. A finding of unsubstantiated means that Although the allegation may have happened, the preponderance of evidence does not prove it although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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