312700019-2-9-2024-59-AS-KHOS-D2DSVK-20240212131254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:44:16 PM

Unsubstantiated

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
12/01/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20231201121801

FACILITY NAME:	TERRACES OF ROSEVILLE, THE		FACILITY NUMBER:	312700019
ADMINISTRATOR:	NATHAN CONDIE		FACILITY TYPE:	740
ADDRESS:	707 SUNRISE AVE		TELEPHONE:	(916) 786-3277
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	199	CENSUS: 200	DATE:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Business Director: Shaunte Burnett		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff restrained resident in care by placing wheelchair or obstacles to prevent resident from getting out of bed.

INVESTIGATION FINDINGS:

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On 02/09/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 12/01/2023. LPA met with Business Director, Shaunte Burnett, and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews with facility staff and obtained pertinent documents relevant to the complaint investigation such as residents’ (R1 and R2) physician’s report, incident reports, confidential facsimile transmittal, medication administration records, and medication list.

Continue on page LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231201121801

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: 02/09/2024

NARRATIVE

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Allegation: Facility staff restrained resident in care by placing wheelchairs or obstacles to prevent resident from getting out of bed. – Unsubstantiated.

According to the complainant, unspecified staff left R1 alone in bed for long hours, and placed wheelchairs or obstacles to prevent R1 from getting from bed independently.

The Department received an interview statement from a resident (R1). R1 indicated staff entered R1’s room at approximately 1-2 AM and placed wheelchair and electric scooter on the right side of the bed which prevented R1 from using transfer pole to get in and out of bed.

The Department reviewed R1’s physician’s report and level of care assessments. The physician’s report indicated R1 had bladder impairment, bowel impairment, and requires continuous bed care. R1 can care for all personal needs, bath self, dress/groom self, feed self, and care for own toileting needs. R1 is not able to ambulate without assistance. According to R1’s level of care assessment, R1 requires standby assist when toileting.

The Department interviewed and received statements from a total of five (5) facility staff and two (2) residents. Interview statement received from staff (S1 and S5) indicated has not observed R1’s wheelchair or electric scooter placed in the area to prevent R1 from getting in and out of bed. Interview statement received from staff (S3) stated based on the pictures that R1 provided to the facility the incident did occur and it is true that staff (S6) barricaded R1’s bed area with wheelchair and electric scooter. S3 stated did not observe the incident in person. S3 stated staff (S6) are no longer working at the facility. The Department attempted to interview S6 via telephone.

The Department conducted a thorough investigation and is unable to determine if the above allegation did occur. Due to the information above, CCL finds the 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.

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

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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