<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701156
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:12:30 PM

Document Has Been Signed on 08/02/2023 04:12 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: 6DATE:
08/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Orchid DamrichobTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8-2-23 at 1:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident which occurred on 7-8-23. LPAs met with Administrator Orchid Damrichob and explained the purpose of the visit. LPAs reviewed incident report dated 7-10-23, physician's report for resident1 (R1), needs and service plan for R1, LPAs also interviewed Administrator. Based on record review and interview, it was revealed that R1 sustained an unwitnessed fall on 7-8-23 resulting in a hip fracture. It was further revealed that after discovery of the fall facility staff notified hospice and sent R1 to hospital after receiving consent from R1's responsible person. Additionally, based on interview and record review, R1 was and continues to receive hospice services and has a history of agitation and wandering. Needs and service plan reviewed revealed R1 requires constant supervision, supervision with ADLs, and assist with all ADLs including toileting. Based on review of incident report, facility staff heard a call for help from R1 and found R1 on floor, called Administrator and assisted R1 back to bed. A review of hospice waiver states facility will provide additional staff as necessary to meet needs of residents in care. During the incident on 7-8-23, 1 care staff was on duty for 6 residents. Two of six residents received hospice services, multiple other residents have dementia care needs and incontinent needs.

As a result of today's case management, citations are issued under Title 22, Division 6 and Health and Safety Codes. A civil penalty in the amount of $500 is issued in addition to citation due to injury relating to violation of Health and Safety Code Section 1569.312(a). At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). 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: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/02/2023 04:12 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/02/2023 at 02:54 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
HSC
1569.312(a)

1
2
3
4
5
6
7
Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to develop and submit an updated plan of care for R1 outlining needs for care and supervision. Plan to be integrated with hospice care plan. Plan to be submitted to LPA by POC due dates.
8
9
10
11
12
13
14
Based on record review and interview, R1 sustained a fall with injury due to lack of appropriate required supervision as stated in R1's plan of care. This posed an immediate health, safety and resident rights risk to residents in care.
8
9
10
11
12
13
14
Type A
08/03/2023
Section Cited
CCR87465(g)

1
2
3
4
5
6
7
Incidental Medical and Dental Care. (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 was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will read regulation 87465(g) and submit a signed decalration of understanding to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, Licensee did not ensure an immediate call to 9-1-1 following the discovery of a R1's fall and pain on 7-8-23. This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee will ensure completed staff training on regulation 87465(g). Training date to be submitted to LPA by POC due date with proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/02/2023 04:12 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/02/2023 at 03:12 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
87405(d)1)

1
2
3
4
5
6
7
Administrator Qualifications and Duties. (d) The administrator shall have the qualifications...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to review regulations regarding care and supervision and regulatory definition of care and supervision, and submit a signed declaration of understanding to LPA by POC due date. Sections referenced: H&S Code 1569.312(a) and H&S Code Section 1569.2.
8
9
10
11
12
13
14
Based on interview and record review, Administrator did not ensure a care and supervision level for R1 consistent with R1's written plan of care resulting in a fall with injury. This posed and immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3