Sacramento Senior Living Ii

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not properly supervise client resulting in elopement

On 05/15/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to open and closed the complaint allegation outlined above. LPA met with caregiver Netani Tuivu to explain the purpose of the visit. A brief interview was conducted with administrator Salote Lewis via telephone call. The census is 5 with 1 facility staff. It was alleged that facility staff did not properly supervise client resulting in elopement. This investigation included interviews with staffs and records review. In an interview with both administrator Salote Lewis and caregiver Netani Tuivu, both admitted that resident 1 (R1) left the facility unsupervised. Based on records review it was learned that on 04/30/25, R1 left the facility unsupervised and was brought back to the facility by law enforcement. Per R1's LIC 602, Physician Report dated 10/02/23 R1 has a history of wandering behavior and is unable to leave the facility unassisted. Based on the interviews conducted during the investigation process and rethe state’s words, verbatim · CDSS document, May 15, 2025 · control 27-AS-20250507142611

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility is not meeting the hygiene needs of a resident in care. Staff did not ensure that resident was wearing shoes when being transported to the hospital.

On 08/12/2024 at 8:46 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care giver Melvin Hinds and explained the purpose of the visit. LPA Lee explained the purpose of this visit is to deliver complaint findings for the allegations above. Care giver called administrator Salote Lewis and was not able to get a hold of the administrator. The current census is 5 with 1 facility staff. A brief interview with conducted with care giver Melvin. Allegation: Facility is not meeting the hygiene needs of a resident in care. It was alleged that the facility is not meeting the hygiene needs of a resident in care. This investigation consisted of observations, records reviewed, interviews with staff and residents. Throughout the course of the investigation, LPA Lee observe 5 out of 5 residents on 05/30/2024 and all the residents appeared to be in good hygiene. 5 out of 5 residents did not observe to have any outgrown fingernaithe state’s words, verbatim · CDSS document, Aug 12, 2024 · control 27-AS-20240521154127

Allegation investigated: Staff did not administer resident's medication

On 7-25-24 at 12:47pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss investigative findings for the allegation noted above. LPA met with lead caregiver Melvin Hinds and explained the purpose of the visit. Administrator Salote Lewis was notified via phone of LPA's visit and purpose and gave permission for lead caregiver to sign in her absence. Allegation: Staff did not administer resident's medication. During this investigation, LPA conducted interviews with four residents and Administrator. LPA also reviewed facility file documentation including medication log sheets. Additionally, LPA conducted a facility observation on 7-19-24. LPA Truong conducted additional investigation for this allegation. Based on record review, it was revealed that facility staff did not administer as prescribed eye drop medication for resident5 (R5) on 6/28/2024 at 12pm, 4pm, an 8pm. Based on record review, it was revealed that medication Amlodipine 5mg was not adminthe state’s words, verbatim · CDSS document, Jul 25, 2024 · control 27-AS-20240508134903

Allegation investigated: Staff did not prevent residents from having access to illegal drugs Staff inappropriately touched resident

On 7-19-24 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with lead caregiver and explained the purpose of the visit. Administrator Salote Lewis was contacted by LPA via phone and gave permission for lead caregiver to sign in her absence. During this investigation, the Department conducted interviews with three staff members and three residents in care. Allegation: Staff did not prevent residents from having access to illegal drugs. Based on interviews conducted, it was revealed R1 was witnessed by a staff member to have returned to the facility “high” after leaving facility with R1’s family member for an outing, however, was not revealed by staff that R1used drugs in the facility. Additionally, it was revealed that no corroborated statements existed to suggest illegal drug use within the facility by any residents. {Cont. on 9099C} Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 19, 2024 · control 27-AS-20240508134903

Allegation investigated: Staff did not ensure resident's room was free from odors

On 5/15/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a complaint visit regarding the allegations above. LPA met with Administrator Salote Lewis and explained the purpose of the visit. Based on observations and interviews conducted, LPA discovered urine odor throughout this facility especially in the resident bedrooms. The administrator acknowledged that there is urine odor in the facility and corroborated that staff will need to clean the bedrooms more frequenlty. As a result of this investigation, LPA finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, May 15, 2024 · control 27-AS-20240508134903

Allegation investigated: Personal Rights: Facility staff touched a resident inappropriately

Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Sacramento Senior Living II RCFE on 3/7/24 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Misivono Qadroka and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations because R1, in discussing the allegations over two interviews clarified that he was initially uncomfortable with a staff member of the same gender assisting with bathing but has come to understand that staff is only assisting with daily living and is not a sexual act. R1 states they have made adjustments to bathing and R1 can wash his body with assistance of staff. Staff interviewed denied any issues with bathing and that R1 prefers to wash parts of himself and there have been no issues. S1 states R1's physithe state’s words, verbatim · CDSS document, Mar 7, 2024 · control 27-AS-20231215155605

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff was sleeping while at work.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Sacramento Senior Living II on 1/31/23 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA met with staff and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because two of the resident's interviewed confirmed that they could not wake a staff member with pages sent from the resident's bedroom following an incident where a resident fell in their room overnight. Residents attempted to page the staff member for assistance with no response and called 911 for assistance. Staff interview confirmed the events as described by residents. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is recethe state’s words, verbatim · CDSS document, Jan 31, 2024 · control 27-AS-20231219121552

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident was left in soiled garments for an extended length of time Staff did not ensure resident hygiene needs were met

Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 11/6/23. LPA met with Staff Misivono Qadroka and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on resident interviews, resident (R2) and (R3) corroborated that staff (S2) had left R3 in soiled garments overnight. R3 reported that they needed to be changed, but S2 ignored and didn’t change R3 until the next morning. Based on interviews conducted during the course of this investigation, it was learned that residents’ hygiene needs were not being met. It was learned that showers were not being provided to resident (R1) as R1 appeared dirty. It was learned that S2 didn’t know when the last time residents were showered. Continued on 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Dec 6, 2023 · control 27-AS-20231106165238

Allegation investigated: Medications: 1) Staff mishandled a resident's medication while in care. 2) Staff have inadequate record keeping for a resident.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Sacramento Senior Living II RCFE on 12/1/23 at 1:00pm to inform the licensee of complaint allegations mentioned above and to deliver the findings. LPA met with Staff Misivono Qadroka and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated because LPA reviewed resident records and medication administration records and observed several instances for all residents where the medication administration was not documented according the the facility program and title 22 regulations. There was no documentation for any residents medication administration on today's date. Additionally LPA observed that there were gaps in the medication administration due to alleged waiting for pharmacy refills but LPA determined the refill request was made after the recommended date of the refill and resident was not adminithe state’s words, verbatim · CDSS document, Dec 1, 2023 · control 27-AS-20231127140349

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.