577000418-5-17-2021-21-AS-VBRN-C34MZU-20210517100343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 05/17/2021
Date Signed: 05/17/2021 10:04:06 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	GRAND RIVER CARE CENTER-WEST		FACILITY NUMBER:	577000418
ADMINISTRATOR:	PAZ, DIANA		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BOULEVARD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	30	CENSUS: 10	DATE:	05/17/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diana Paz, Administrator		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 17, 2021 Licensing Program Analyst (LPA), Victoria Brown, met with Diana Paz, of Grand River Care Center-West for a case management visit to follow up on a substantiated allegation of serious bodily injury. On March 29, 2018, the Department conducted a complaint investigation which alleged the staff failed to seek medical attention for a resident (R1) in a timely manner. The allegation was substantiated, and the licensee was cited for a violation of California Code of Regulations (CCR) Title 22, § 87465(g) - Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. On January 10, 2018 at 12:00 a.m., R1 fell in a bathroom resulting in an open fracture of R1’s ankle and staff did not to seek medical attention for over nine (9) hours. The investigation revealed that on January 10, 2018, at approximately 12:00 a.m., R1 sustained an unwitnessed fall.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (915) 247-4200
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GRAND RIVER CARE CENTER-WEST	FACILITY NUMBER: 577000418
	VISIT DATE: 05/17/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff 3 (S3), who responded to R1 after hearing screams, stated that S3 found R1 on the floor next to R1’s bed and S3 picked R1 up and put R1 back on R1’s bed. S3 stated that S3 gave R1 Tylenol for pain and placed an ice pack on R1’s left leg. S3 stated there was no indication that R1 had a serious injury and that at the time, no swelling was observed. S3 stated that S3 checked R1 shortly before S3’s shift ended (between 6:00 a.m. and 7:00 a.m.) and that R1 stated that R1 was fine. S3 stated that S3 informed the morning shift staff that R1 had fallen during the night before S3 left the facility.

Morning shift staff interviews revealed that when they arrived for work on January 10, 2018, at approximately 7:30 a.m. R1 informed staff that R1 had fainted the night before and was unable to get out of bed. Staff 1 (S1) stated that S1 observed a “red spot that looked like a rug burn” on R1’ lefts ankle, and recommended R1 be seen by a physician. Interviews with staff revealed that R1 refused because R1 wanted to be cleaned up from soiling R1’s self and wanted to speak to R1’s sister. Staff 2 (S2) stated that S2 assisted R1 into a wheelchair to take a shower, and that R1’s left leg did not look broken. Staff stated that R1 then contacted R1’s sister by telephone shortly after R1 was assisted with taking a shower. A little later, R1’s sister called the facility and instructed staff to call 9-1-1.

On January 10, 2018, R1 was transported via ambulance and admitted to a general acute care hospital at 1:14 p.m. The physical exam upon admission indicated that R1’s left ankle exhibited swelling (significant with contusion). External rotation of left foot with some deformity as well as small skin rent.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (915) 247-4200
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GRAND RIVER CARE CENTER-WEST	FACILITY NUMBER: 577000418
	VISIT DATE: 05/17/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Records further indicate that medical professionals could see underlying bone while viewing the wound. R1’s hospital medical records indicate that R1 was diagnosed with a small open fracture wound (skin rent) as a result of the fracture. According to medicinenet.com, “an open fracture is a fracture in which the bone is sticking through the skin.”

Based on medical records, interviews and facility record reviews, the licensee did not provide adequate care and supervision to resident on January 10, 2018, by failing to ensure that resident was provided medical attention in a timely manner. Records indicate that R1 sustained an unwitnessed fall at approximately 12:00 a.m. and was not seen by a medical professional until 1:14 p.m. The licensee did not seek medical attention for over 13hours. The licensee’s failure to ensure R1 was provided medical attention in a timely manner caused R1 to experience prolonged extreme pain from the fracture that required hospitalization which is a serious bodily injury.

At the time of the complaint visit on March 29, 2018, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a serious bodily injury.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (915) 247-4200
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GRAND RIVER CARE CENTER-WEST	FACILITY NUMBER: 577000418
	VISIT DATE: 05/17/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, May 17, 2021, the Department is issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. A copy of the LIC 421D was given to Diana Paz and originals were signed on file.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Diana Paz signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (915) 247-4200
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4