<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002855
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:35:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
03/30/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230330080535
FACILITY NAME:DOLCE VITA HOME CAREFACILITY NUMBER:
315002855
ADMINISTRATOR:NATALYA ANDREYEAFACILITY TYPE:
740
ADDRESS:141 HINCKLEY CTTELEPHONE:
(916) 521-5393
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
05/04/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natalya Andreyea, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect led to resident sustaining pressure injury
Staff left resident unattended in 2 soaking wet diapers and a pad for extended periods
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Natalya Andreyea during today’s inspection.

The department investigated allegation, “Staff neglect led to resident sustaining pressure injury”. The department interviewed relevant parties and reviewed medical documentation. On 2/10/23, R1 was admitted to home health for reasons unrelated to her skin/pressure injuries. On 3/7/23, redness was noted on R1 by home health. During R1’s weekly home health visit on 3/14/23, home health staff noted that R1 had a stage three pressure injury on her coccyx. Between 3/7/23 and 3/14/23, facility staff did not report the pressure injury or the worsening of the pressure injury to home health. Facility staff indicated that they were not aware of R1’s pressure injury until late March.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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 59-AS-20230330080535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: DOLCE VITA HOME CARE
FACILITY NUMBER: 315002855
VISIT DATE: 05/04/2023
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
Facility staff had no documentation or record indicating that home health was contacted regarding the pressure injury. Facility staff were responsible for R1’s activities of daily living that included bathing/showering. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

The department investigated allegation, “Staff left resident unattended in 2 soaking wet diapers and a pad for extended period”. The department interviewed relevant parties and reviewed medical documentation. On 3/29/23 R1 was seen by home health to provide wound care. Home health worker observed R1 to be wearing three sets of diapers/briefs and two of three were wet. Home health worker indicates R1 was probably sitting in the wet depends for a couple of hours due to the amount of urine that was observed. The department interviewed administrator in which she stated resident was never in 2 depends, however staff do use a depend and a pad inside the depend during the night. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230330080535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: DOLCE VITA HOME CARE
FACILITY NUMBER: 315002855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
1
2
3
4
5
6
7
Administrator agrees to complete a training from an outside vendor for all care staff concerning wound and skin care. Date of training to be sent into LPA by 5/05/23. Once completed, a copy
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews and record review, R1 had a stage three pressure injury and did not report worsening of pressure injury to home health which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
of training documentation and sign in sheet of what staff attended to be sent to LPA.
Type B
05/19/2023
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625 Managed Incontinence . (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
1
2
3
4
5
6
7
Administrator agrees to complete a training from an outside vendor for all care staff concerning continence care. Copy of training documentation and sign in sheet
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews, the licensee did not keep R1 clean and dry for 1 resident which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
of what staff attended to be sent to LPA by 5/19/23.
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: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3