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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002853
Report Date: 01/19/2024
Date Signed: 01/19/2024 01:29:39 PM

Document Has Been Signed on 01/19/2024 01:29 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIGNATURE LIVING ON CAMELIA AVENUEFACILITY NUMBER:
315002853
ADMINISTRATOR:OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:CaregiverTIME COMPLETED:
01:45 PM
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On 1/19/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with designee, Shenel Phang . LPA spoke with Administrator by phone regarding the report and findings.

On 12/14/23, LPA Mknelly, conducted a visit and issued a citation based on the information available at the facility at the time regarding an incident report received by the department on 12/12/23. The 12/12/23 incident report was regarding a hospital visit for R1 on 12/7/23. LPA conducted a records review regarding R1. Records found that R1 was admitted to this facility on 10/25/23. Discharge instructions from the referring hospital identified R1 as having wounds that require daily ongoing wound care. Between 10/25/23 and 12/7/23 R1 did not receive home heath wound care at the facility.

Following the 12/14/23 visit, LPA Mknelly collected the following additional records regarding R1’s wounds care history: referring hospital wound care and discharge status of wounds, area hospital records for 12/7/23- 12-9/23, and current home health records.

Referring hospital wound care records, received from the hospital by LPA on 1/11/24, showed that on 10/25/23, R1 was transferred to this facility with a stage IV Sacrococcygeal pressure injury, a Full thickness (non- pressure) injury to left thigh, contractures requiring continued physical therapy. Report continued...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853
VISIT DATE: 01/19/2024
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10/25/23 discharge instructions recommended daily dressing changes to the Sacral and sacrococcygeal pressure injuries and dressing change to the left thigh wound every other day. An appointment for a tele-health follow-up call on 1/30/23. Licensee did not present a record that the 10/30/23 tele-health call occurred.

R1’s LIC 602- physician’s report, dated 9/19/23, noted non-healing wounds.
R1’s LIC 625- Appraisal Needs and Services Plan, dated 11/29/23, listed severe deformity and contractures requiring exercise. There was no wound care plan developed.

On 12/7/23- 12/9/23 area hospital records noted:
HISTORY OF PRESENT ILLNESS:
(R1) brought in by ambulance sent to the emergency department by board and care facility for wound check. Patient reports (R1) is worried for infection as (R1) was just admitted into the hospital one month ago for chronic pressure wounds to his coccyx, elbows, and lower extremities. (R1) is concerned for infection and states the wound to his left lower extremity is more red and starting to become black.
Emergency department diagnosis: Pressure ulcer of sacral region, unspecified stage; Pressure ulcer of left hip, unspecified stage; Pressure ulcer of right hip, unspecified stage and Abrasion of scalp, initial encounter.
R! was admitted for wound care evaluation and for case management to discuss resources for discharge planning. On wound care evaluation patient was found to healing pressure ulcers to sacrum and bilateral hips as well as healing open wound to left anterior thigh unclear etiology as well as abrasion to posterior scalp again of unclear etiology.

R1 returned to the facility on 12/9/24 with orders for Home Health which began on 12/10/24.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853
VISIT DATE: 01/19/2024
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Home health records showed that on 12/22/23 R1 was assessed to have two (2) stage III pressure injuries. One to the coccyx and to low right buttocks. (Note: the buttocks pressure injury was no noted at discharge from the referring hospital.) The injuries were explicitly identified to facility staff. Staff, Nerryrose Kreig , who was informed by Home Health, did not take immediate action to request and exception from licensing or to have R1 seen at a hospital until 1/2/23, at the prompting by LPA Mknelly, for this prohibited health condition. ER doctor determined that R1’s wounds were stage II or less and R1 returned to the facility with continued Home Health Wound care.

Therefore, medical records review found that in addition to the citation issued on 12/14/23 for a lack of a wound care plan for R1, R1 was admitted and knowing retained at the facility with prohibited conditions of Stage III and IV pressure injuries. Those healing wounds were also neglected by facility staff between 10/25/23 and 12/7/23 which severely risked R1’s health and safety.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/19/2024 01:29 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 01/19/2024 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2024
Section Cited
CCR
87615(a)(1)

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Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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R1 is currently stable and receiving appropriate care.

Licensee will submit proof of scheduled training for preappraisals and prohibitted conditions to CCL by the POC date of 1/22/24.
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This requirement was not met based on records review which showed R1 was admitted to the facility with stage IV injuries. This posed an immediate risk to resident health and safety.
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Scheduled training must be completed within 30 days from this date.
Type A
01/22/2024
Section Cited
CCR87465(a)(1)

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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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R1 is currently stable and receiving appropriate care.

Licensee will develop procedures to address, staff knowledge of resident conditions, staff observation for changes to known conditions and response, up to
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This requirement was not met based on records review and statements that found R1 had recommendations for wound care that were not arranged for by the licensee. This posed an immediate risk to the resident.
Civil Penalties are applied.
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call to 9-1-1, when resident conditions need medical care.
Procedure will include staff training.

Procedure to be submitted by the POC date of 1/22/24.
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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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