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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:31:53 PM

Document Has Been Signed on 05/10/2024 02:31 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:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR/
DIRECTOR:		CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Cecelia CandidoTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 5/10/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to a complaint investigation for complaint control number 27-AS-20231213133955. LPA Jensen met with Administrator Cecelia Candido and explained the purpose of today's visit.

During a Non-Compliance Conference on 2/13/24, a discussion took place regarding a wound that Resident 1 (R1) developed while under facility care. The Administrator stated that facility protocol was not followed as the Administrator only called the hospital advice nurse as opposed to sending the resident out to be evaluated by a medical professional.

On 3/12/24 LPA Jensen issued a citation under the above listed compliant number for an allegation that a “resident developed a pressure injury while in care”. The citation issued pursuant to the California Code of Regulations (CCR), Section 87464(f)(1) has been repealed. The repealed citation is being replaced with a citation under CCR section 87466 and civil penalties are being assessed.

See complaint control number 27-AS-20231213133955 for additional investigation details. An exit interview was conducted and a copy of this report and appeal rights were provided.

Lisa RiosTELEPHONE: (916) 969-9685
Maja JensenTELEPHONE: (916) 639-5584
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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Document Has Been Signed on 05/10/2024 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/10/2024
Section Cited
CCR
87466

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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided when such observation reveals unmet needs. When changes ... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician ...
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The Licensee has already completed the plan of correction under compliant number 27-AS-20231213133955. No further plan of correction required.
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This requirement was not met as evidenced by Based on an interview with the Administrator and a review of facility records, medical records and photographs, R1 developed a wound while under facility care that was not reported to R1’s physician. 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.
Lisa RiosTELEPHONE: (916) 969-9685
Maja JensenTELEPHONE: (916) 639-5584

DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024

LIC809 (FAS) - (06/04)
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