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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700438
Report Date: 04/07/2025
Date Signed: 04/07/2025 10:04:24 PM

Unsubstantiated


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
11/15/2024 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20241115093203
FACILITY NAME:ETERNITY CARE HOMEFACILITY NUMBER:
502700438
ADMINISTRATOR:PAYLA, MARIA ALONAFACILITY TYPE:
740
ADDRESS:1704 MOUNT VERNON DRTELEPHONE:
(209) 567-2812
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 3DATE:
04/07/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Care staff Antonio Bugas TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Licensee does not ensure facility staff is adequately staffed to meet residents needs resulting in unwitnessed falls
Facility staff are not meeting residents toileting needs
Facility staff left resident in urine soaked clothing for an extended period of time
Facility staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Care staff Antonio Bugas and who called Administrator Maria Payla and explained the reason for the visit. Administrator Maria Payla gave permission to Care staff Antonio Bugas sign required paperwork. Census: 3
Licensee does not ensure facility staff is adequately staffed to meet residents needs resulting in unwitnessed falls- LPA Lund reviewed facility records, interviewed staff, reporting party, and residents in care. Based on records reviewed, interviews with staff, reporting party, and residents in care. Resident (R1) moved into the facility on 7/11/2024 and moved out on 10/15/2024. LPA Lund reviewed case notes for R1 which stated R1 had two falls during R1 stay at the facility. Care notes reviewed indicate that R1 fell on 10/7/24 and it was addressed by staff. Staff (S1) stated R1 refused emergency help, and first aid was applied. 10/15/2024 R1 fell and refused emergency help. That same morning R1 son came, and paramedics were called. LPA Lund reviewed facility staffing schedule’s from 7/1/2024 through 10/31/2024 revealed two staff on duty consistently residents in care.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
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 3
Control Number 27-AS-20241115093203
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: ETERNITY CARE HOME
FACILITY NUMBER: 502700438
VISIT DATE: 04/07/2025
NARRATIVE
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Based on records reviewed, interviews with staff, reporting party, and residents in care, on the information provided, it was unclear if licensee does not ensure facility staff is adequately staffed to meet residents needs resulting in unwitnessed falls, therefore the allegation was deemed UNSUBSTANTIATED.

Facility staff are not meeting residents toileting needs- LPA Lund reviewed facility records, interviewed staff, reporting party, and residents in care. Based on records reviewed, interviews with staff, reporting party, and residents in care. Resident (R1) had monthly bowl movement records from 7/11/2024 through 10/15/2024. The reports stated when R1 had a bowl movement facility would change R1 depends. Staff interviewed stated that R1 would get their attention when needed to use the restroom. LPA Lund reviewed facility staffing schedule’s from 7/1/2024 through 10/31/2024 revealed two staff on duty consistently residents in care that include staff for the night. LPA Lund reviewed Samaritan Home Health report. R1 was a patient in-home starting on 8/16/2024 through 10/10/2024. R1 had a bowl movement and stated to Samaritan Home staff facility caregivers would change undergarment (Depends) per R1 routine with facility caregivers.

Based on records reviewed, interviews with staff, reporting party, and residents in care, on the information provided, it was unclear if facility staff are not meeting residents toileting needs, therefore the allegation was deemed UNSUBSTANTIATED

Facility staff left resident in urine soaked clothing for an extended period of time- LPA Lund reviewed facility records, interviewed staff, reporting party, and residents in care. Based on records reviewed, interviews with staff, reporting party, and residents in care. Staff interviewed stated that R1 would get their attention when needed to use the restroom. LPA Lund reviewed facility staffing schedule’s from 7/1/2024 through 10/31/2024 revealed two staff on duty consistently residents in care that include staff for the night. LPA Lund reviewed Samaritan Home Health report. R1 was a patient in-home starting on 8/16/2024 through 10/10/2024. R1 had a bowl movement and stated to Samaritan Home staff facility caregivers would change undergarment (Depends) per R1 routine with facility caregivers.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241115093203
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: ETERNITY CARE HOME
FACILITY NUMBER: 502700438
VISIT DATE: 04/07/2025
NARRATIVE
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Based on records reviewed, interviews with staff, reporting party, and residents in care, on the information provided, it was unclear if facility staff left resident in urine soaked clothing for an extended period of time, therefore the allegation was deemed UNSUBSTANTIATED.

Facility staff did not seek timely medical attention for resident- LPA Lund reviewed facility records, interviewed staff, reporting party, and residents in care. Based on records reviewed, interviews with staff, reporting party, and residents in care. Resident (R1) moved into the facility on 7/11/2024 and moved out on 10/15/2024. LPA Lund reviewed case notes for R1 which stated R1 had two falls during R1 stay at the facility. Care notes reviewed indicate that R1 fell 10/7/24 and it was addressed by staff. Staff (S1) stated R1 refused emergency help, and first aid was applied. 10/15/2024 R1 fell and refused emergency help. That same morning R1 son came, and paramedics were called. LPA Lund reviewed Samaritan Home Health report which states R1 had many medical conditions including chronic kidney disease, congestive heart failure and type 2 diabetes.

Based on records reviewed, interviews with staff, reporting party, and residents in care, on the information provided, it was unclear if facility staff did not seek timely medical attention for resident, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of 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 report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3