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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701084
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:36:46 PM

Document Has Been Signed on 10/24/2024 12:36 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:R & E SENIOR CARE, INC.FACILITY NUMBER:
342701084
ADMINISTRATOR/
DIRECTOR:		EMILY PASCUAFACILITY TYPE:
740
ADDRESS:5231 OLIVEHURST WAYTELEPHONE:
(916) 895-4357
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 3DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Emily PascuaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Emily Pascua and explained the purpose of the visit.

Upon arrival, LPAs Moleski and Williams observed a resident (R1) sitting in a chair with large amounts of dark-colored bruising covering their face. LPAs Moleski and Williams asked Pascua about the cause of these injuries, and she said R1 had fallen on 10/21/24. LPA Moleski reviewed an incident report submitted to the Community Care Licensing Division on that same date. According to the incident report, R1 went to the bathroom around 2:30 p.m. and fell, hitting their head and right forearm. Immediately after the fall, R1 exhibited redness to their left eye and forehead, and had a wound on their upper nose. R1's right forearm had an open wound, a skin tear, and bruising, according to the incident report. The report further stated that first aid was provided to R1, including antibiotic ointment and gauze for R1's wounds, and R1's responsible party was notified.

In an interview, Pascua said that 911 was not called. She said that R1's responsible party was texted immediately after the incident and asked whether or not R1 should be sent to the hospital, but R1's responsible party did not respond to her inquiry until the next day. Pascua said that R1's responsible party told her that R1 did not need to be sent to the hospital.

22 CCR Section 87465(g) states that "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." Pascua admitted that 911 should have been called after the incident described above.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084
VISIT DATE: 10/24/2024
NARRATIVE
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LPAs Moleski and Williams reviewed three resident files (R1-R3) and two staff files (S1-S2).

LPA Moleski observed all residents (R1-R3) did not have needs and services plans on file. LPA Moleski observed that R3 was diagnosed with stage three pressure ulcers on both buttocks while at a skilled nursing facility (SNF) as of 2/4/23, according to admission records from the SNF. R3's LIC 602 dated 2/15/23 indicated that R3 still had at least one stage 3 pressure ulcer on their buttocks. R3's preadmission appraisal, signed by Pascua, the resident, and the resident's responsible party as of 2/21/23, indicated that R3 had two stage three pressure ulcers on both buttocks. R3 signed this facility's admission agreement on that same date, 2/21/23. Pascua confirmed that R3 had never received hospice care while at this facility. Pascua said the wounds have since healed.

LPAs Moleski and Williams toured the facility with Pascua and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

While touring the facility, LPAs Moleski and Williams and Pascua observed an unlocked bathroom cabinet which contained a disinfectant. In a different bathroom in a resident room, LPAs Moleski and Williams and Pascua observed an unlocked cabinet with a container of powdered cleaner with bleach. Additionally, LPAs Moleski and Williams and Pascua observed multiple medications for R3 left in unlocked drawers and cabinets in that bathroom. The medications included various creams, eyedrops, powders, and lidocaine patches. R3 is not able to store their own medications, according to R3's most recent LIC 602 on file, dated 3/3/23.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives in the kitchen.

LPA Williams interviewed one staff member (S1) and two residents (R1-R2). This facility is hereby cited per 22 CCR Sections 87465(g), 87615(a)(1), 87465(h)(2), and 87309(a), and HSC Section 1569.695(e)(2). An exit interview was held with Pascua. Appeal rights and a copy of this report were left with Pascua.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/24/2024 12:36 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/24/2024 at 10:57 AM
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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(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..."

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interview, emergency medical services were not called after a resident fell, hitting their head and arm and suffering bruises, redness, and an open wound, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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4
Licensee agrees to write a signed statement acknowledging the requirement to telephone 911 immediately after an incident occurs which threatens a resident's health by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/24/2024 12:36 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/24/2024 at 11:59 AM
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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, two cleaners were left unlocked in resident bathrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee agrees to replace a broken lock in a common bathroom and agrees to remove bleach cleaners from R3's bedroom by POC due date. Licensee agrees to send LPA Moleski photographs of each correction.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, various medications were left in unlocked and accessible storage areas in R3's bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee agrees to remove the medications and to provide photographs of the storage areas by POC due date showing that the medications have been removed.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/24/2024 12:36 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/24/2024 at 11:59 AM
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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(1)
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 sores (dermal ulcers).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, R3 was admitted to this facility with a prohibited health condition, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee agrees to provide a written statement acknowledging the requirements regarding prohibited health conditions by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/24/2024 12:36 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/24/2024 at 11:59 AM
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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, R1-R3 had no needs and services plans on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee agrees to provide LPA Moleski with needs and services plans for all residents by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


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