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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002248
Report Date: 08/30/2022
Date Signed: 08/30/2022 11:06:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220524125646
FACILITY NAME:RODNEY KEINATH COUNTRY HOMEFACILITY NUMBER:
347002248
ADMINISTRATOR:KEINATH, RODNEYFACILITY TYPE:
735
ADDRESS:8267 CHESTER DRIVETELEPHONE:
(916) 682-9485
CITY:SACRAMENTOSTATE: CAZIP CODE:
95830
CAPACITY:6CENSUS: 6DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rodney KeinathTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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-Resident sustained a fracture while in care
-Facility did not seek resident timely medical attention
INVESTIGATION FINDINGS:
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On 8/30/22 at 9:40 AM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with staff Ester Maramis and explained the purpose of today's visit. Administrator Rodney Keinath showed up at a later time.
Regarding the allegation of Resident sustained a fracture while in care, the Department found the following; based on interview and record review, it was determined that Resident 1(R1) did sustain a fracture in care. It couldn't be determined how or when this fracture happened but R1's medical records did indicate there was a fracture.

Regarding the allegation of Facility did not seek resident timely medical attention, the Department found the following; based on interview and record review, it was determined that the incident with R1 happened in the late afternoon, but R1 was taken to the hospital the next morning.
Report Continued on LIC9099-C...


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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 3
Control Number 27-AS-20220524125646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RODNEY KEINATH COUNTRY HOME
FACILITY NUMBER: 347002248
VISIT DATE: 08/30/2022
NARRATIVE
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Based on interview and record review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

Exit interview held, Appeal Rights discussed and given, Copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220524125646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RODNEY KEINATH COUNTRY HOME
FACILITY NUMBER: 347002248
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee has agreed to conduct an in-service training on the responsibilities of care and supervision and on providing medical care for the residents. POC due date 8/31/22 by Close Of Business (COB)
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Based on interview and record review, the Licensee did not ensure R1 was properly evaluated for injury due to a fall. This poses an immediate health and safety risk to residents in care.
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Type A
08/31/2022
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee has agreed to conduct an in-service training on reassessing residents in care. POC due date 8/31/22 by Close of Business (COB)
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Based on interview and record review, the Licensee did not ensure R1 received proper medical attention. Staff stated R1 seemed uncomfortable, experiencing some discomfort while changing R1. This poses an immediate health and safety risk to 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3