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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701156
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:20:42 PM

Document Has Been Signed on 03/23/2023 12:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:GESMUNDO, PAOLOFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
03/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Orchid DamrichobTIME COMPLETED:
12:30 PM
NARRATIVE
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On 3-23-23 at 11:00am, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit regarding infection control practices, reporting requirements, and medication practices. LPA met with Administrator Orchid Damrichob and explained the purpose of the visit. LPA conducted facility observation on 1-19-23, reviewed facility file documentation for resident1 (R1), and conducted interview with Administrator on 1-19-23. Based on observation, record review and interviews, the following was determined: (1) On 1-19-23, it was determined that R1 contracted scabies and was not cleared of contagious disease. During facility tour, LPA did not observe isolation carts in place to promote appropriate infection control practices for residents, staff, and visitors. Additionally, based on interview, it was determined that an isolation cart was not present after facility staff learned of R1’s diagnosis of scabies. (2) Upon learning of R1’s scabies diagnosis after R1’s hospitalization on 1-4-23 for an unrelated condition, it was further determined through interview and record review that facility did not report incident to licensing department per regulatory requirements. Repot was eventually received on 1-26-23. (3) Based on review of care notes for R1 and interview conducted, it was determined that R1 experienced behavioral episodes between the dates of 11/6/2022 and 1/4/2023 which were not identified on R1’s needs and service plan upon his admission on 6/10/2022. Further interview and record review revealed needs and service plans were not updated to reflect new onset of behaviors and accompanying necessary interventions. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
VISIT DATE: 03/23/2023
NARRATIVE
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(4) On 1-19-23, it was determined through interview that on 1-17-23, facility staff observed a R1’s responsible party handling medication for R1 which included the process of cutting one medication in half. It was further determined that facility staff did not effectively intervene during this event to promote a provision of safety for residents in care.

As a result of today's case management, citations are issued under Title 22, Division 6 and listed on 809D. An immediate civil penalty in the amount of $250 is issued today in addition to citations due to repeat violation within a 12-month period. An exit interview was conducted with Orchid Damrichob and a copy of this report was left with Orchid. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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Document Has Been Signed on 03/23/2023 12:20 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/23/2023 at 10:53 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2). Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee will read regulation 87468.1(a)(2) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and observation, licensee did not ensure a properly stored isolation cart outside of R1’s room during a scabies outbreak to promote safety. This posed an immediate health and safety risk to residents in care.
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Licensee and staff will complete training on infection control practices. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks after date of citation issuance.
Type A
03/24/2023
Section Cited
CCR87405(h)(5)

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87405(h)(5). Administrator Qualification and Duties. (h)The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement was not met as evidenced by:
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Licensee and staff will ensure completed training on safe medication handling procedures and physician orders. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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Based on interview, licensee did not ensure a service of safety for R1 in that a responsible person was allowed to handle and cut medication for R1 without appropriate staff intervention occurring. This posed an immediate health and safety risk to residents in care.
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Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.
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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


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Document Has Been Signed on 03/23/2023 12:20 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/23/2023 at 11:00 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D). Reporting requirements. (a) Each licensee shall furnish to the licensing agency such reports…(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met as evidenced by:
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Licensee will read regulation 87211(a)(1)(D) and submit a signed declaration of understanding to LPA by POC due date.
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Based in interview and record review, licensee did not ensure the timely reporting of R1 contracting scabies. This posed a potential health and safety risk to residents in care.
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Type B
04/03/2023
Section Cited
CCR87463(a)

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87463(a) Reappraisals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…This requirement was not met as evidenced by:
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Licensee will read regulation 87463(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, licensee did not ensure the appropriate and required updates to R1’s needs and service plan. This posed a potential health and safety 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


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