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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002929
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:43:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240530142459
FACILITY NAME:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jane CarinoTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident sustained unexplained bruising
INVESTIGATION FINDINGS:
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On 9/26/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to deliver the finding of the allegation cited above. LPA met with Caregiver and explained the purpose of the visit.

During the course of this investigation, LPA conducted extensive file reviews and interviews regarding the allegation cited above.

Please continue to LIC 9099-C for the result of the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 2
Control Number 59-AS-20240530142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DEAN ESTATE
FACILITY NUMBER: 345002929
VISIT DATE: 09/26/2024
NARRATIVE
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LIC 9099-C

Allegation: Resident sustained unexplained bruising.
Based on file review conducted, incident report submitted to Community Care Licensing revealed that R1 was transported to the emergency room for evaluation on March 30, 2024 then after five days on April 4, 2024, R1 was transported to a skilled nursing facility. Based on file review conducted R1 was discharged from skilled nursing and returned to the facility on April 22, 2024. Based on shower skin sheet for R1, it revealed on April 23, 2024 R1 was documented to have scratch marks on R1's right lower thigh and foot. Additionally, it was documented of discoloration/bruising on R1's left arm. The following was observed and documented by Assistant Administrator. Based on resident care notes reviewed, it was revealed on May 1, 2024 facility faxed R1's primary care physician for advisory regarding "old discoloration and spreading and color changed". On May 3, 2024, it revealed "resident's discoloration is getting better and fading. Will continue to monitor and report changes." Based on R1's Mini-Mental State Examination conducted on April 23, 2024, it revealed there was a list of eleven (11) questions with the maximum score of 30, R1's score was zero (0) with a second try refusal. Based on R1's preplacement appraisal on April 20, 2024, it was documented that R1's mental condition was listed as "confused and disoriented with hallucinations sometimes".

Based on interview conducted with Administrator, it revealed that R1 has dementia and is often forgetful where R1 informed Administrator and Long Term Care Ombudsman that R1 does not know what happened. Interview with R1 revealed that R1 does not recall living at the facility, but R1 does remember having a big bruising. R1 was unable to state if R1 was injured at skilled nursing facility prior to returning to the facility or at the facility.

With the information obtained, LPA found the allegation to be unsubstantiated as R1 is unable to recall the incident along with facility having skin check documentation of bruising present when R1 returned to he facility after skilled nursing discharge. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of the report was provided.  
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2