9/12/2019

Internal Web Data

Department of

SOCIAL SERVICES
Community Care Licensing

COMPLAINT INVESTIGATION REPORT
Facility Number: 347000947
Report Date: 09/12/2017
Date Signed 09/12/2017 10:33:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL
SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR.,
STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2017 and conducted by Evaluator Erin Sumner
PUBLIC
FACILITY NAME: NORA'S HOME CARE #2
ADMINISTRATOR:BERCI, ELEONORA
ADDRESS:
5813 KENNETH AVENUE
CITY:
FAIR OAKS
CAPACITY:
12
MET WITH:

Eleonora Berci, Administrator

COMPLAINT CONTROL NUMBER: 27-SC20170613090207
FACILITY
NUMBER:
FACILITY TYPE:
TELEPHONE:
STATE: CA
ZIP CODE:
CENSUS: 11
DATE:
UNANNOUNCEDTIME BEGAN:
TIME
COMPLETED:

347000947
740
(916) 536-0240
95628
09/12/2017
09:00 AM
10:45 AM

ALLEGATION(S):
1 resident was allowed to have food that was prohibited
2
3
4
5
6
7
8
9
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erin Sumner conducted an unannounced visit to the facility on 9/12/17
at 9:00 AM for the purpose of delivering findings for the above allegation. LPA met with the administrator,
Eleonora "Nora" Berci. LPA let Nora know the reason for the visit.
During the complaint visit, LPA reviewed residents file, reviewed medical records from Kaiser Roseville
Hospital, reviewed medical records from Pine Creek Care Center, skilled nursing facility and conducted
interviews. The administrator admitted that she knew R-1 needed a pureed diet and had gotten distracted
and accidentally gave R-1 solid food. The administrator also admitted that she forgot to tell the other
caregiver that R-1 had a pureed diet as that caregiver was off the day R-1 was admitted to the facility.
Staff confirmed he was given Macaroni, Stew, and applesauce. On 6/3/17, R-1 was having secretions
from R-1's mouth and spitting the secretions out. The administrator sent R-1 to the Hospital right away.
Hospital records document that the R-1 told the hospital R-1 felt that R-1 had somethnig stuck in his
throat. The hospital released R-1 later that evening on 6/3/17 after deciding R-1 had bronchatis and gave
R-1 Albuterol. R-1 was released back to the facility. Later that evening R-1 was given his medications
with applesauce. He began throwing up and aspirating. The administrator sent R-1 back to the hospital
an hour after he was released from the hospital.
Medical records documented R-1 having Macaroni, Meat, Applesauce and a Cucumber or Zucchini in his
esophagus after the resident expired on 6/17/17 due to Aspiration Pneumonia and food in R-1's
Esophagus.

https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=347000947&inx=7

1/3

 9/12/2019

Internal Web Data

Based on LPAs observations and interviews which were conducted and record interview(s), the
preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be
SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are
being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, Copy of
report given.
As a result of this incident, and the resident passing, the violation warrants a civil penalty assessment. At
this time, the civil penalty assessment is under review per H&S Code Section 1569.49 and a civil penalty
determination is pending by the department.
Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Antoinette Wood
LICENSING EVALUATOR NAME: Erin Sumner
LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (916) 263-4707
TELEPHONE: (916) 214-5020
DATE: 09/12/2017

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

DATE: 09/12/2017

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 2

Control Number 27-SC-20170613090207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
(Cont)

CALIFORNIA DEPARTMENT OF SOCIAL
SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR., STE 270
SACRAMENTO, CA 95833

FACILITY NAME: NORA'S HOME CARE #2
DEFICIENCY INFORMATION FOR THIS PAGE:
Deficiency Type
POC Due Date /
Section Number

Type A
09/13/2017
Section Cited
CCR
87555(b)(7)

Type B
09/15/2017
Section Cited
CCR
87405(d)(1)

FACILITY NUMBER: 347000947
VISIT DATE: 09/12/2017

DEFICIENCIES

1
2
3
4
5
6
7

1
2
3
4
5
6
7
8
9
10
11
12
13
14

PLAN OF CORRECTIONS(POCs)

87555(b)(7) General Food Service
Requirements-The following food
service requirements shall apply:
Modified diets prescribed by a
resident's physician as a medical
necessity shall be provided.Administrator admitted she gave R-1
solid food on accident and not pureed
food.

1
2
3
4
5
6
7

87405(d)(1) Administrator Qualifications and Duties-The
administrator shall have the
qualifications specified in Sections
87405(d)(1) through (7). If the licensee
is also the administrator, all
requirements for an administrator shall
apply.-Knowledge of the requirements
for providing care and supervision
appropriate to the residents.Administrator admitted she did not
know that R-1 had an Esophagus
problem and just knew he needed
pureed food. R-1's 602 states he has
Dysphagia and Oropharyngeal phase.

1
2
3
4
5
6
7

Administrator stated she will make a
chart for each resident that needs a
special diet and medications and will
post it in the kitchen. Administrator shall
hold an in-service training will all staff
on the new chart for residents with
special diets. Administrator shall send a
copy of the chart and the staff signature
sheet to LPA by the POC due date of
9/13/17.
Administrator shall write a plan of the
steps she will take when accepting
residents to ensure an incident like this
does not occur in the future. The written
plan shall be submitted to LPA by the
POC due date of 9/15/17.

8
9
10
11
12
13
14

1
2
3
https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=347000947&inx=7

1
2
3
2/3

 9/12/2019

Internal Web Data

4
5
6
7

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: Antoinette Wood
LICENSING EVALUATOR NAME: Erin Sumner
LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (916) 263-4707
TELEPHONE: (916) 214-5020
DATE: 09/12/2017

I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
LIC9099 (FAS) - (06/04)

https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=347000947&inx=7

DATE: 09/12/2017
Page: 2 of 2

3/3