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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002623
Report Date: 06/06/2023
Date Signed: 06/06/2023 10:53:07 AM


Document Has Been Signed on 06/06/2023 10:53 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:BY THE RIVER ASSISTED LIVINGFACILITY NUMBER:
525002623
ADMINISTRATOR:O'SULLIVAN, LINDA KAYFACILITY TYPE:
740
ADDRESS:1095 LAKESIDE DRIVETELEPHONE:
(530) 727-9010
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:6CENSUS: DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Linda O'Sullivan - licenseeTIME COMPLETED:
11:00 AM
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06/06/02023 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with licensee Linda O’Sullivan. Today’s visit is regarding an incident that occurred on 05/30/2023 and was reported to licensing on 05/30/2023. It was reported that on 5/30/2023 Resident 1 (R1) was found on the floor of their room with their right leg twisted sideways. Staff called 911 and R1 was transported to the ER, x-rays were performed and R1 was diagnosed with a small fracture of the upper arm. R1’s arm was placed in a sling and R1 returned home to the facility.

On 6/05/2023 a second incident report was submitted reporting that 911 was called and R1 had been transported to the hospital on 6/03/23 due to continued pain that was not being managed by pain medication. The facility reported that R1 was showing further decline. R1 was hospitalized for 24-hour observation. Facility was notified by R1’s family that R1 has passed away at the hospital on 06/04/2023.

During the course of the investigation, it was learned that staff had just checked on R1 directly before R1 fell and observed R1 to be in their bed at that time. Staff walked out of R1's room and immediately after they left the room they heard R1 fall. R1 stated they reached for a blanket on a chair and fell. The facility had planned to open R1 to hospice services when they returned to the facility but R1 passed away at the hospital during the subsequent hospitalization where they were admitted for observation.

No deficiencies were cited as a result of today’s visit.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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