Citation Watch 2018 – Psychsocial-related Citations for California in 2018

Prepare yourself for your  upcoming survey with this list that covers all of 2018  Social Service related citations in California in 2018. 

Alameda County Medical Center D/P SNF
15400 Foothill Boulevard, San Lcandro

  • B $1000 Elopement Physical Environment
  • 1/16/2018

The facility failed to monitor the functionality of a resident’s WanderGuard signaling band and left a resident whose care plan stated he required supervision, unsupervised on 10/29/17. The resident’s WanderGuard was not activated at three locations, and when a CNA saw the resident unsupervised off the unit, she asked if he wanted to go upstairs and lie down and he said no. When she went to check on him again, he was gone. Citation # 020013736.


Kyakameena Care Center
2131 Carleton Street, Berkeley

  • B $2000 Physical Environment
  • 10/04/2018

From 5/14/18-7/9/18, the nursing home did not have a working call system, and asked residents to use their personal cell phones or a manual call bell to call facility staff for assistance. Facility staff were inconsistent in responding to at least two residents who used their cell phones and the manual call bells. The facility was cited for failing to maintain a nurses’ signal system in operating order. Citation # 020014454.


Oakland Heights Nursing and Rehabilitation
2361 East 29th Street, Oakland

  • B $1000 Neglect
  • 04/16/2018

A resident with impaired respiratory function was to be provided breathing treatments as ordered and the staff was to observe and report signs of respiratory distress. On 12/18/17, the resident was reported screaming for help because she was having problems breathing. She called 911 because no one was coming to help her. According to the ER notes, the resident was suffering from shortness of breath which was worsening. The facility was cited for failing to provide the resident with breathing medications as ordered by the physician and not answering calls of distress from the resident. Citation # 020014000.


OrindaCareCenter,LLC
11 Altarinda Road, Orinda

  • B $2000 Fall
  • 10/04/2018

On 7/30/18, the facility driver who was taking resident back to the facility after their dialysis treatment left one resident outside on the curb by herself in a wheelchair while going back into the building to get another resident. The driver had not affixed the wheelchair’s break and the wheelchair started to roll, and the resident slid out falling to the pavement. The fall caused abrasions to the forehead and a fractured femur. The facility was cited for failing to ensure that the resident received adequate supervision to prevent an accident. Citation # 020014448.


Dycora Transitional Health – Manchester
3408 E Shields Ave, Fresno

  • B $2000 Physical Environment
  • 10/24/2018

On 7/2/18, during a transfer from the bed onto a wheelchair, the resident’s leg was sliced by the jagged metal on the end portion of the bed’s side rail slicing his calf and requiring a transfer to the hospital and 17 staples to close the wound. A plastic cap would normally cover the exposed metal. When interviewed, the maintenance supervisor stated he had been aware for over a month and a half that plastic side rail caps were missing on resident beds leaving rough metal edges exposed. The facility was fined for failing to ensure the residents’ environment was free of accident hazards. Citation # 040014527.


Golden Living Center – Shafter
140 E Tulare Ave, Shafter

  • B $2000 Mandated Reporting Physical Abuse
  • 10/16/2018

On 8/20/18, an 88 year old resident told her daughter that someone in the facility had slapped her left hand, and the daughter reported the incident to the Social Services Designee (SSD). The SSD stated nothing was done because she had determined that the resident was making false allegations. The facility was cited for failing to report an allegation of abuse to the Department within 24 hours. Citation # 120014455.

  • B $2000 Mandated Reporting Physical Abuse
  • 10/30/2018


On 6/15/18, a 66 year old resident complained that a CNA was rough and abused her giving care. The facility did not report the alleged abuse to the Department until over two months later on 8/17/18. The facility was cited for failing to report an abuse allegation in a timely manner. Citation # 120014512.


Country Villa Wilshire Convalescent Center
855 N Fairfax Ave, Los Angeles

On 3/15/16 a 94 year old wheelchair-bound resident who had poor safety awareness was found at the back of the facility. The resident had an unwitnessed fall down six flights of stairs resulting in traumatic brain injury, multiple skin tears and a fractured spine. On 4/18/18, during an interview, the administrator stated there was no investigation as to why the resident was outside the facility without supervision. The facility was cited for failing to ensure that a resident who was identified to have poor safety awareness was provided with adequate supervision. Citation # 910014446.


San Fernando Post Acute Hospital
12260 Foothill Blvd, Sylmar

  • B $2000 Bed Hold Evictions
  • 08/23/2018

A resident was hospitalized on 4/19/18 but was not given his mandatory bed hold “due to aggressive behavior.” The resident was refused readmission when he was ready to come back to the facility and the facility was cited for failing to offer a bed hold and refusing to readmit the resident. Citation # 920014359.


Valley Palms Care Center
13400 Sherman Way, North Hollywood

  • B $2000 Evictions Notification
  • 09/06/2018

Three residents were discharged to board and care homes without appropriate notice and without sending notice to the long term care Ombudsman in February and March 2018. The board and care homes were unlicensed and identified by an outside placement agency, as the social services director did not know that verifying the facility’s license was necessary. The facility was cited for failing to notify the Ombudsman and failing to ensure a safe and orderly discharge for the three residents. Citation # 920014393.


Windsor Gardens Rehabilitation Center of Salinas
637 E Romie Ln, Salinas

  • B $2000 Infection Neglect Patient Care
  • 10/05/2018

On 9/8/18, a resident was observed to have chills and a temperature of 104.5. The resident’s physician ordered antibiotics and a urine culture. The culture tested positive for a urinary tract infection (UTI) on 9/9/18, but the physician never followed up after receiving the lab results, and the nurses did not make any effort to reach the physician or change the resident’s care plan for ten days, until 9/19/18, when the resident was sent to the hospital with sepsis. At that time, the resident was nauseous, with a swollen stomach. The facility was cited for failure to provide quality care. Citation # 070014461.


Napa Valley Care Center
3275 Villa Ln, Napa

  • A $20000 Care Plan Patient Care
  • 09/14/2018

A 69 year old male resident was admitted to the facility on 12/31/16 with sepsis, kidney failure and diabetes. On 1/5/17, the resident was sent to the hospital after attempting to stab himself with a fork. The resident had severely low blood glucose levels at the time of hospitalization. He died on 1/8/17. The facility was cited for failure to clarify incomplete physician orders related to the diabetes, and failure to assess the resident’s blood glucose when he acted irrationally by attempting to stab himself. Citation # 110013195.


Piner’s Nursing Home
1800 Pueblo Ave, Napa
B $2000 Evictions Mandated Reporting Patient Rights 10/22/2018
On 4/25/18, the facility was cited for failure to notify the Ombudsman of a resident’s discharge, which prevented the Ombudsman from advocating for the resident. The resident was admitted to the facility on 4/16/18 for swelling in the left knee, and was discharged on 4/25/18. According to the Social Services Director, the resident was discharged because she “completed her therapy,” which is not a valid reason for discharge. The Ombudsman stated the facility had not been informing her office of resident discharges. Citation # 110014306.


Roseville Point Health & Wellness Center
600 Sunrise Avenue, Roseville

  • B $2000 Evictions
  • 07/14/2017

On 10/4/16, a female resident who could not walk or ambulate and was totally dependent on staff for dressing, toileting, hygiene, and transferring from bed to chair was sent to an independent “room and board” home identified by a placement agency. The room and board was completely unequipped to provide care to the resident. She could not even get through the front door of the home so she was placed in the garage where she defecated on herself and could not get up from the floor. Within two hours, she had to be transferred to a hospital. The facility was cited for failing to ensure a safe discharge, creating risk of injury or neglect. Citation # 030013349.

  • B $2000 Bed Hold Evictions
  • 04/26/2018

A male resident with paraplegia was hospitalized on 1/25/18 for a urinary tract infection. On 1/29/18, the resident was medically stable and ready to return to the facility. The facility refused readmission, claiming it had discharged the resident despite having no documentation the resident was given a written discharge notice. The facility was cited for failing to readmit the resident after his hospitalization was no longer necessary. Citation # 030014015.


Brookdale Rancho Mirage
72201 Country Club Dr, Rancho Mirage

  • B $200 Evictions Transfer
  • 09/20/2018

During the investigation of a discharge complaint, it was discovered the facility failed to send a copy of a resident’s discharge notice to the local long term care Ombudsman program. The failure may have led to the resident being discharged on 4/20/18 without having an advocate to ensure a safe discharge or without a clear understanding of his appeal rights. Citation # 250014398.


Premier Care Center For Palm Springs
2990 E Ramon Rd, Palm Springs

  • B $500 Notification Transfer
  • 09/20/2018

On 3/28/18, the facility failed to ensure that a written notification of transfer was provided to the resident, the resident’s representative or local long-term care ombudsman when the resident was transferred to an acute hospital. The facility was cited for failing to provide the required notice. Citation # 250014312.


Riverwalk Post Acute
4000 Harrison St, Riverside

  • B $2000
  • 10/02/2018

After one resident pinched and twisted the cheek of another resident, facility staff separated the two and noted Mandated Reporting Physical Abuse the incident, but failed to properly report state and law enforcement agencies properly as required by law. Citation # 250014428.


Double Tree Post-Acute Care Center
7400 24th Street, Sacramento

  • B $2000
  • 10/18/2018

Prior to discharging a male resident on 2/26/18, the facility did not provide him or his responsible party with a written discharge notice and failed to send a copy of a notice to the long term care Ombudsman. Citation # 030014496.


Pioneer House
415 P Street, Sacramento

  • B $2000 Bed Hold Evictions
  • 10/19/2017

On 3/23/17, a female resident was sent to the hospital for a -behavioral episode” where she threw silverware during lunch time. The hospital made several attempts to have the resident readmitted but the facility refused, despite the resident’s bed hold rights and a “court order” to take her back. The facility was cited for failing to readmit the resident. Citation # 030013512.


Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento

  • B $2000 Evictions
  • 10/30/2018

On 10/1/16, Windsor Care Center of Sacramento transferred a resident with dementia to a local hospital for striking out at other residents. Ten days later, he was cleared for readmission by the hospital doctors but he was not readmitted. On 2/23/17, an administrative hearing was held and Windsor was ordered to readmit the resident. It ignored the order. The facility claimed it had no available bed for the resident but that was untrue. As of mid-2018, the resident had still not been readmitted. The facility was cited for failing to readmit the resident and fined a total of S2,000. Citation # 030014525.


Golden Living Center-Chateau
1221 Rosemarie Lane, Stockton

  • B $2000 Bed hold Evictions
  • 10/09/2018

A male resident who had lived at the facility for eight years was hospitalized on 4/26/17 after striking another resident. The hospital doctor found the resident had no acute care need and ordered readmission but the facility refused. The facility claimed it could no longer care for the resident but did not perform a legal discharge. The facility was cited for failing to readmit the resident after he was medically cleared for readmission. Citation # 030013532.


Kindred Transitional Care & Rehabilitation – Valley Gardens
1517 Knickerbocker Drive, Stockton

  • B $2000 Bed Hold Evictions
  • 10/05/2017

A resident was sent to the hospital on 7/14/17. When he was cleared by the hospital doctors to return to the facility on 7/25/17, the facility refused to readmit him. The facility was under the mistaken belief that it did not need to readmit residents after their 7-day bed hold expired, even if they had available beds. The facility was cited for failing to timely readmit the resident. Citation # 030013526.


Hearts & Hands, Post Acute Care & Rehab Center
2990 Soqucl Ave, Santa Cruz

  • B $2000 Care Plan Evictions Notice
  • 10/30/2018

On 9/24/18, a resident was admitted to the facility with diagnoses including anxiety disorder. The facility had a care conference on 9/25/18 which the resident did not attend. The facility also failed to give her a copy of a notice from her insurance provider requesting additional information to authorize payment. The facility was cited for failing to involve the resident in discharge planning. Citation # 070014542.


Vacaville Convalescent And Rehabilitation Center
585 Nut Tree Ct, Vacaville

  • B $2000 Notification Transfer
  • 09/21/2018

On 5/6/18, a resident was transferred to the hospital. The facility did not inform the Ombudsman office of the transfer, despite a regulation requiring such a notice. The facility was cited for failing to inform the Ombudsman of the transfer. Citation # 110014267.

  • B $2000 Notification Transfer
  • 9/21/2018

On 5/3/18, a resident was transferred to the hospital. The facility did not inform the Ombudsman office of the transfer, despite a regulation requiring such a notice. The facility was cited for failing to inform the Ombudsman of the transfer. Citation # 110014266.

  • B $2000 Notification Transfer
  • 9/21/2018

On 4/14/18, a resident was transferred to the hospital. The facility did not inform the Ombudsman office of the transfer, despite a regulation requiring such a notice. The facility was cited for failing to inform the Ombudsman of the transfer. Citation # 110014265.


Modesto Post Acute Center
159 E Orangeburg Ave, Modesto

  • A $20000 Evictions
  • 10/1/2018

An 87 year old female resident with severe dementia who had lived at the facility for nearly three years went out to lunch with a family member on 2/14/18. When the resident had not returned the next morning, she was “discharged.” Multiple calls to the family member were not answered but eventually he told the facility he was keeping the resident for 14 days. After being reminded the resident needed her medications, the family member brought the resident back to the facility on 2/16/18. The facility refused to take her back, prompting a 911 call and transfer to a hospital, where she was treated for bronchitis. The resident was readmitted from the hospital on 2/26/18. The facility was cited for failing to follow its own procedures for resident discharge. It did not inform the resident’s physician, develop and communicate a post-discharge plan of care, or enlist the police to ensure the resident’s safety. Citation # 040014444.

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