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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 030317773
Report Date: 09/30/2022
Date Signed: 09/30/2022 02:01:25 PM

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
07/05/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220705135931
FACILITY NAME:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR:JULIE KRAMERFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:49CENSUS: 31DATE:
09/30/2022
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Julie KramerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility failed to assist resident with hygiene
Facility failed to assist resident with feeding
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA met with Administrator Julie Kramer, and explained the purpose of the visit.

The department has determined the following as it relates to following allegations: Facility failed to assist resident with hygiene, facility failed to assist resident with feeding

LPA reviewed facility files. The facility had a food intake log for residents on the assisted living side of the facility. The staff members track the percentage of food and fluid intake for each meal.

LPA observed the facility on 09/30/2022. LPA observed the facility to have 3 staff for the assisted living and 2 staff on the memory care side assisting residents with feeding throughout the meal times. During the visit, LPA also observed staff conducting rounds and assisting residents with ADLs.
Continues on LIC 9099-C...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
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 5
Control Number 27-AS-20220705135931
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: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
VISIT DATE: 09/30/2022
NARRATIVE
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...Continued from LIC 9099
LPA interviewed 4 staff. According to an interview with staff 1 (S1), all residents need some sort of assistance with ADLs and there are two residents on the lower level service side that require staff to feed them for all meals. S1 stated the facility has staff that are designated to feed the residents either in the dining hall or in their room. S1 stated staff also assist residents who need assistance with utensils. Staff will observe the residents for the duration of their meal time. The facility documents daily percentage of food intake on a sheet of paper, which is kept in the medication room. S1 does not know of any resident not being fed or hygiene not being attended to.  According to Staff 2 (S2), there are two additional residents on the higher level service side that require assistance with feeding. S2 stated one resident recently needed to have services added to their care plan due to concerns raised by their family. S2 stated after services were added to their "Quick Mar" system, services were implemented right away. S2 stated, "the only time a person is not fed is if they refused to eat." Staff are to ask residents multiple times, save the plate, and document how much they ate or refused. According to S3 and S4, there was never a time where a resident did not get fed unless they chose not to eat.

LPA Valerio received photo documentation for resident 3 (R3). LPA reviewed 4 pictures from July 4th, 2022 and 5 pictures from July 14th, 2022. LPA observed R3 to have a thick layer of oral thrush on the inside of R3's mouth. The thrush was an opaque/white color that was on the surface of the tongue, in between teeth, and on inside of the cheek. According to mayoclinic.org, "oral thrush is a condition in which the fungus Candida albicans accumulates on the lining of your mouth." To prevent oral thrust, mayoclinic.org recommends to rinse one's mouth, brush teeth twice a daily, floss daily, etc. According to the pictures, R3 suffered neglect due to the facility not ensuring to assist resident with hygiene needs.

According to the responsible party for R3, R3 cannot speak; however, can communicate by answering yes or no questions. The questions are asked and R3 will squeeze the hand. When R3 was asked about food and hygiene, R3 answered yes to not being helped for feeding and yes to no one brushing teeth.

Based on records review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided to Administrator Julie Kramer.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220705135931
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: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2022
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4)Personal assistance and care as needed by the resident...such as.. eating... This requirement was not met as evidenced by:
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Licensee added updated care plan to R3's QUICK MAR prior to delivery of findings. Licensee stated the facility will re-evaluating residents needs and ensure needs are met by adding additional specific needs in Quick Mar system. LPA to receive an update on which residents had their care plan changed by POC due date.
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Based on records review and interviews, the facility did not ensure R3 was fed with the assistance of staff, which poses an immediate health and safety risk to resident in care.
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Type B
10/28/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan...shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...:(1) The licensee shall arrange,.. assist...medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee stated an in-service for all staff will be conduct on Relias and have a person come in to provide training on oral hygiene and ADLs. LPA to receive supportive documents on in-service training by POC due date
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Based on records review and interviews, the facility did not ensure R3 dental needs were met, which poses an potential 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5