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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:59:02 PM

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
11/29/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221129122235
FACILITY NAME:TERRACES OF ROSEVILLE, THEFACILITY NUMBER:
312700019
ADMINISTRATOR:NATHAN CONDIEFACILITY TYPE:
740
ADDRESS:707 SUNRISE AVETELEPHONE:
(916) 786-3277
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:199CENSUS: 190DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Business Office Manager: Shaunte BurnettTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are neglecting residents' needs.
INVESTIGATION FINDINGS:
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On 07/28/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final findings Community Care Licensing received on 11/29/2022. LPA met with Business Office Manage, Shaunte Burnett, and explained the purpose of the visit.

During the course of investigation, the Department interviewed facility staff, residents in care, and obtained pertinent documents relevant to the complaint investigation such as, four residents’ (R1, R2, R3, & R4) physician’s report, face sheet, level of care assessment, service plan, medication list, physician’s orders, medication administration records (MAR), employee roster, and resident roster.

Continue on page LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
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 5
Control Number 25-AS-20221129122235
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: 07/28/2023
NARRATIVE
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CCL received allegation stating facility staff are neglecting resident’s needs. The Department conducted interviews and received statement from a total of six (6) facility staff and two (2) residents. The Department requested and reviewed resident (R5) physician’s report and service plan. According to R5’s physician’s report, R5 cannot manage own medication. R5 has bowel and bladder impairment. R5 wears briefs and is not capable of caring for own toileting needs. According to R5’s service plan, staff is to observe R5 for redness, discoloration, or open areas to skin for risk of skin break down. R5 requires a 1-person assist with transfers. R5 needs 2-person assist with toileting.

The Department conducted interviews with a total of six (6) facility staff and two (2) residents. According to staff (S1), the facility has been experiencing staffing issues. Interview statement received from S1 indicated, there are three (3) shifts, there is supposed to be a total of 5 caregivers and 2 Med Tech working per shift. Staff had brought up staffing concerns to management and was told that they are working on hiring more care staff. Interview statement received from four (4) staff (S1, S3, S4, & S5) indicated there were concerns about S2 neglecting residents in care by not changing their briefs. Residents are left in soiled briefs. A total of 4 staff out of 6 staff indicated, R5 has been left in soiled briefs on multiple occasions. Interview received from R6 indicated, staff did not want to change R5 and didn’t have time to do so. R6 stated it would take about an hour for staff to assist R6. R6 requires a 2-3 person assist but was cleared with 1 person assist. Interview statement received from S5 indicated, there are about 5 residents that are not being changed and all incidents were reported to management. Staff were not changing residents during the NOC shift.

Due to this information CCL finds the 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.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20221129122235
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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/04/2023
Section Cited
CCR
87625(b)(3)
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Managed incontinence 87625 (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility
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Executive Director agrees to provide training on incontinence care and resident centered care. Licensee will provide training plans by POC due date, 8/4/2023.
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remains free of odors from incontinence. This was not met as evidenced by: Based on interviews, facility failed to ensure R5 were not kept clean and dry. This poses an immediate health, safety, and or personal rights risk to resident in care.

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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/29/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221129122235

FACILITY NAME:TERRACES OF ROSEVILLE, THEFACILITY NUMBER:
312700019
ADMINISTRATOR:NATHAN CONDIEFACILITY TYPE:
740
ADDRESS:707 SUNRISE AVETELEPHONE:
(916) 786-3277
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:199CENSUS: 190DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Business Office Manager: Shaunte BurnettTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Residents are being over medicated while in care.
INVESTIGATION FINDINGS:
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On 07/28/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final findings Community Care Licensing received on 11/29/2022. LPA met with Business Office Manage, Shaunte Burnett, and explained the purpose of the visit.

During the course of investigation, the Department interviewed facility staff, residents in care, and obtained pertinent documents relevant to the complaint investigation such as, four residents’ (R1, R2, R3, & R4) physician’s report, face sheet, level of care assessment, service plan, medication list, physician’s orders, medication administration records (MAR), employee roster, and resident roster.

Continue on page LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20221129122235
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: 07/28/2023
NARRATIVE
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CCL received allegations stating residents are being over medicated while in care. The Department reviewed R1, R2, R3, and R4’s LIC 602’s, medication lists, MAR, service plan, and level of care assessments. Facility is correctly using the MAR and found no discrepancies. The Department conducted interviews and received statement from a total of six (6) facility staff and two (2) residents. Interview statements received from a total of 6 staff indicated, they have not observed residents being over medicated while in care. Interview statement received from resident (R5) indicated, they have not missed a medication and has no issues with staff when assisting with medications.

The Department could not find enough evidence to confirm nor deny this allegation happened. The Department finds this allegation to be UNSUBSTANTIATED - meaning 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.

No deficiencies being cited for today’s visit.

Exit interview conducted and report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5