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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:06:37 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
08/15/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240815133121
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: 185DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Kristine Clawson, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not prevent resident from eloping
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kristine Clawson, to open a complaint into the allegation listed above.

During today's visit, LPA toured the facility, obtain documentation pertinent to the investigation, and interviewed ED, Resident Care Director (RCD), and Building Service Director (BSD).

Per Special Incident Report (SIR) sent to the Department, the facility reported that staff were unable to locate resident (R1) on the premises on 8/14/24 at approximately 6:00 PM. Facility called 9-1-1 and filed a missing person's report. Resident was located by police at approximately 8:00 PM in the tall grass field behind the property.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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 3
Control Number 59-AS-20240815133121
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: 08/21/2024
NARRATIVE
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Interview with BSD indicated that they observed R1 inside the facility walking with their walker at approximately 5:30 PM. Facility records showed that R1 was in the dining room for dinner, which is served between 4:00 PM to 6:00 PM.

Police Department dispatch call records indicate that facility contacted local police department at 7:14 PM to report R1 missing. Interview with RCD indicated that they made the 9-1-1 call. Dispatch call records indicate that RCD reported to police department that R1 was last seen by staff at 3:45 PM. Missing Person Report indicates that R1 was last seen at approximately 3:45 PM and not reported to police department until 7:00 PM that same day. Report indicates that staff stated R1 is often very confused and gets lost very easily. Report indicates that R1 was found by officer in the woods to the rear of the facility, in which R1 was stuck in tall brambles.

Interview with ED indicated that, after conducting an internal investigation following the incident and prior to reporting to CCLD, the facility discovered that BSD had last seen R1 inside the facility at 5:30 PM. Interview with RCD indicated that, when they reported to 9-1-1, the staff who they spoke with reported last seeing R1 in the facility at 3:45 PM and RCD reported such to local police department. Interview with RCD indicated that staff at the facility did not report R1 missing to RCD until 6:41 PM, 41 minutes after staff observed R1 missing. ED and RCD stated that, following incident, R1 has moved to a higher level of care outside the facility. During visit, LPA observed field behind property to be maintained.

LPA observed that R1's LIC 602A Physician's Report dated 4/16/2024 indicates that R1 has Mild Cognitive Impairment and is unable to leave the facility unassisted.

Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is 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. 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240815133121
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: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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Facility will conduct an in-service training following the AWOL with all staff regarding missing residents/elopement. Facility will provide proof of training to LPA by the POC due date of 8/22/24.
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Based on records reviewed and interviews conducted, the facility did not ensure that resident R1 was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
08/22/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:
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Facility will conduct an in-service training following the AWOL with all staff regarding reporting protocols. Facility will provide proof of training to LPA by the POC due date of 8/22/24.
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Based on records reviewed and interviews conducted, the facility did not ensure to contact 9-1-1 timely after observing R1 AWOL from the facility, which poses an immediate health, safety, and personal rights risk to residents 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: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
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