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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 12/05/2024
Date Signed: 12/05/2024 01:23:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
07/19/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240719112743
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ermelinda SiebenthalTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Medications:
1) Staff is mishandling the residents medications
2) Staff is inappropriately administering medication
Neglect/Lack of Supervision:
1) Staff did not provide adequate care and supervision to a resident.

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 12/5/24 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA reviewed medication administration records for three (3) of the five (5) current resident's in care. LPA observed staff who administer medications are signing off medications administered prior to the medications being given to the resident. LPA observed one medication for R1 that is ordered to be administered every other day, documented as being administered daily. R1 has been over-medicated for the medication Ferosul as medicaion order is for every other day and is documented as adminstered daily.
Report Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 6
Control Number 27-AS-20240719112743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 12/05/2024
NARRATIVE
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 LPA observed and received statements from staff member of combining prescription medication contents from older prescriptions to new bottles. LPA observed medications marked as administered for R2 not present at the facility. LPA also observed insulin medication for R2 not refrigerated as directed prior to first use.

Additionally, LPA reviewed current staff schedule and observed the Licensee scheduled for 122 hours for the week of December 1st through the 7th with assigned overnight care duties. LPA reviewed resident records and pre-placement appraisals and needs and services and observed three of the five files reviewed included documentation of needed overnight supervision as a result of residents diagnosis of dementia. LPA and Licensee discussed the overnight shift duties and licensee did provide statements to LPA that there are times where there is no awake overnight care staff on duty.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of medications and neglect/lack of supervision is substantiated.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240719112743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA reviewed of three resident medication administration
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Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months.
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records which documented medications that had not yet been given to the residents which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
12/06/2024
Section Cited
CCR
87465(h)(1)(a)
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Incidental Medical and Dental Care: The preservation of medicines requires refrigeration, if the resident has no private refrigerator. This requirement was not met as evidenced by LPA observations of insulin medication not stored in a refrigerator prior to first use as directed
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Licensee has agreed to conduct medication training for all staff members who assist with medication administration and obtain a lock box to ensure medications are stored in fridge and inaccessible to residents in care.
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on the prescription directions which poses an immediate health safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240719112743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87465(h)(5)
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Incidental Medical and Dental Care: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by LPA review of centrally stored medications and statements
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Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months. (Mondays)
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obtained from staff member that they have transferred medications from one prescription container to another which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
12/06/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA review of R1's medication administration records which showed documentation of a medication
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Licensee has agreed to conduct medication training for all staff members who assist with medication administration. medication administration records will be emailed to LPA weekly for review for the next three months.
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ordered to be given every other day is documented as being administered to R1 daily which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240719112743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
87705(c)(4)(A)
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In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or
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Licensee is in process of hiring an overnight shift staff member and will provide documentation of staff member start date by the POC due date.
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observation to require awake night supervision. This requirement was not met as evidenced by LPA observations of staff schedule and statements obtained form the licensee that there are times where there is not an awake staff member on duty which poses a potential health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6