525002575-12-7-2021-25-AS-RKNT-C9GRBB-20211207115227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002575
Report Date: 12/07/2021
Date Signed: 12/07/2021 11:53:19 AM

Document Has Been Signed on 12/07/2021 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	D & S CARE HOMES, LLC		FACILITY NUMBER:	525002575
ADMINISTRATOR:	BORTZ, JR., DAVID L.		FACILITY TYPE:	735
ADDRESS:	320 CHRISTINA DRIVE		TELEPHONE:	(530) 727-6141
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 5		CENSUS: 5	DATE:	12/07/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	David Bortz - Licensee		TIME COMPLETED:	12:00 PM

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12/072021 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a case management investigation. LPA met with licensee-administrator David Bortz and explained the purpose of the visit. Prior to initiating the complaint investigation LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves. Additionally LPA was screened by facility staff.

The reason for the visit is an incident report that was received on 12/03/2021, concerning an incident that occurred on 12/02/2021 in which it was reported that a resident was unable to bear weight on their right side, had a small bruise on their right hip and their upper thigh/hip area was swollen. At the hospital it was determined that the resident had a fractured hip. Resident was admitted to the hospital on 12/02/21 and surgery was performed on 12/05/2021 in which pins were placed.

The administrator stated that the resident will be discharged from the hospital to skilled nursing in order to obtain appropriate physical therapy.

LPA reviewed and obtained the following documents: Resident's Physician's Report, medication list, and IPP. Review of resident's Physicians Report revealed they are non-ambulatory and are able to transfer independently to and from bed and are able to ambulate without assistance.

Continued on LIC809-C

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: D & S CARE HOMES, LLC	FACILITY NUMBER: 525002575
	VISIT DATE: 12/07/2021

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LPA Knight asked the administrator how the injury may have ocurred.

Administrator stated that the resident falls about once every 6 months. The resident used to ambulate without the assistance of devices. Resident had a fall in April 2021 after which they were prescribed a walker for ambulation. The resident is required to use their walker when they leave their bedroom, but often chooses not to use their walker in their room although the administrator encourages them to do so. It is unknown how the resident sustained the injury as there were no witnesses that saw them fall.

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was emailed to licensee/administrator David Bortz.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC809 (FAS) - (06/04)

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