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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 07/30/2025
Date Signed: 07/30/2025 10:05:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
05/12/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250512100337
FACILITY NAME:TERRACES OF ROSEVILLE, THEFACILITY NUMBER:
312700019
ADMINISTRATOR:CLAWSON, KRISTINEFACILITY TYPE:
740
ADDRESS:707 SUNRISE AVETELEPHONE:
(916) 786-3277
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:199CENSUS: 158DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kristine Clawson, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging residents' medications.

Staff do not meet the qualifications to administer residents' medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to deliver findings into the complaint allegations listed above.

During the investigation, LPA conducted interviews, conducted a medication count, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff are mismanaging residents' medications.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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 4
Control Number 59-AS-20250512100337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TERRACES OF ROSEVILLE, THE
FACILITY NUMBER: 312700019
VISIT DATE: 07/30/2025
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
26
27
28
29
30
31
32
LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated March 27, 2025 for an incident that occurred on March 22, 2025 regarding a medication error. SIR states that, on March 22, 2025, staff gave R4 a cup of their morning medications and set a cup of their spouse's medications on the counter of their apartment while preparing a patch for application. R4 picked up their spouse's cup and started to take their spouse's medications by mistake. R4 ingested five (5) of their spouse's medications. R4 was reported tired but with no adverse side effects. SIR states R4 was monitored and follow-up training with med-techs was scheduled.

On May 15, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that had three (3) tabs over the amount documented. R1's MAR did not indicate any refusals or missed passes of medication. LPA observed three (3) medications for R3 that were either over or under the amount documented. Documentation for R3 did not indicate any refusals or missed passes and did not provide an explanation for medications under the amount documented.

Allegation: Staff do not meet the qualifications to administer residents' medications.

LPA reviewed the facility's Plan of Operation on file with the Department. Regarding training for medication aides, the facility's Plan of Operation states the following: "The annual medication training includes 8 hours of in-service training on medication-related issues in each succeeding 12-month period."

LPA observed training documentation kept at the facility for staff members S1, S2, and S3. LPA observed S2 and S3 to have documentation showing that they received necessary training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 started at the facility as a Medication Aide starting 2019 and received initial training in accordance with Title 22, the Health and Safety Code, and the facility's Plan of Operation. LPA observed that S1 did not complete annual medication training in accordance with the facility's Plan of Operation for the years of 2020, 2022, 2023, and 2024. LPA observed that S1 was in the process of successfully completing their annual medication training for the year of 2025.
** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250512100337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TERRACES OF ROSEVILLE, THE
FACILITY NUMBER: 312700019
VISIT DATE: 07/30/2025
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
26
27
28
29
30
31
32
Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. A civil penalty in the amount of $250 was assessed for the date of July 30, 2025 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250512100337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TERRACES OF ROSEVILLE, THE
FACILITY NUMBER: 312700019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will conduct an inservice with staff regarding medication documentation. Facility will submit to LPA information regarding in-service training by POC due date of 7/31/2025.
8
9
10
11
12
13
14
Based on medication count and records reviewed, the facility did not ensure that 2 of 3 residents were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
A civil penalty in the amount of $250 was assessed due to a repeated violation.
Type B
08/15/2025
Section Cited
CCR
87208(a)
1
2
3
4
5
6
7
87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. (…) This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will ensure that all staff administering medications receive training in accordance with the facility's plan of operation. Facility will create a plan on how to ensure staff are meeting training requirements and submit plan to LPA by POC due date of 8/15/2025.
8
9
10
11
12
13
14
Based on records reviewed, the facility did not ensure that 1 of 3 staff administering medications were receiving training in accordance with the facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4