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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920074
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:04:49 PM

Document Has Been Signed on 11/15/2024 01:04 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:WHOLESOME ELDERLY ON MATHISFACILITY NUMBER:
345920074
ADMINISTRATOR/
DIRECTOR:		NOEL ESTILLOREFACILITY TYPE:
740
ADDRESS:7131 MATHIS COURTTELEPHONE:
(916) 678-0268
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Noel Estillore (phone), Administrator and Martha Szatmari, Assistant Administrator TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Assistant Administrator, Martha Szatmari, and caregiver, Fnu Jahanvi, and stated reason for the inspection. LPA was informed there are currently (5) residents living in the home and (1) resident is under hospice care. LPA observed all residents to be present during the inspection.

LPA discussed the incident involving resident (R1) leaving the facility unattended on 10/12/24, at 10:00 am, with both staff present and with Administrator, Noel, by phone. Administrator Designee, Juan Ramirez, also called by phone to discuss the reason for today's inspection and the incident. Today's discussion revealed that (R1) was able to leave the care home through the back patio door and side gate, as the alarm was turned off on the door, and (R2) had left the gate open. Staff (S1) confirmed she was present at the time (R1) left, and she had no idea he went outside, as he was watching television in the common area after breakfast, and she was in an adjacent room. (S1) stated the police arrived at the care home around 10:30 am to request emergency papers for (R1) and to inform staff they would be taking him to the hospital after he was found to have fallen nearby, sustaining a lip laceration and scratches on his head.

All interviews confirmed that (R1) had never attempted to leave the care home unattended before, and left because he was looking for his car. Medical documentation shows (R1) has a diagnosis of Dementia and cannot leave the facility unattended. Hospital paperwork shows (R1) was treated for a laceration of lip, head injury, has Dementia and was discharged on 10/12/24 (9:43 pm). The facility completed an incident report and emailed it to the regional office email on 10/22/24, which was inadvertently forwarded to another LPA. The assigned LPA did not receive the report until 11/13/24. The Administrator updated (R1's) care plan on 10/22/24 to reflect a change in mental status requiring resident to need closer supervision. An appointment will be scheduled today with (R1's) primary care physician to discuss any follow up needed. An updated physician's report will be requested again and a copy provided to the Department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued. Exit interview with Assistant Administrator. Copy of report and appeal right given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 01:04 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 11/15/2024 at 12:34 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: WHOLESOME ELDERLY ON MATHIS
FACILITY NUMBER: 345920074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2024
Section Cited
CCR
87705(c)(4)

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87705 Care of Persons with Dementia.(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct staff training on AWOL prevention and protocols.

Facility to submit documentation to LPA by fax by 11/29/24.
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Based on interviews conducted, the Licensee did not ensure that resident (R1) was unable to leave the facility unassisted, on 10/12/2024, which posed an immediate health and safety risk to residents in care. The exit door alarm was not activated due to being turned off and has since been turned back on.
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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.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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