312700019-6-3-2021-27-AS-APEZ-C42TNS-20210616145309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 06/03/2021
Date Signed: 06/03/2021 12:32:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2020 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201218154929

FACILITY NAME:	TERRACES OF ROSEVILLE, THE		FACILITY NUMBER:	312700019
ADMINISTRATOR:	JASMINE RIDENOUR		FACILITY TYPE:	740
ADDRESS:	707 SUNRISE AVE		TELEPHONE:	(916) 786-3277
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	199	CENSUS: 108	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Ryan Mussato		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not administer resident’s medication per physician’s order.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced on 6/3/2021 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 12/18/2020. LPA met with Executive Director, Ryan Mussato, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents such as resident’s (R1’s) physician report, medical discharge documents, level of care assessment, unusual incident/injury report, and Medication Administration Records (MAR): Staff did not administer resident’s medication per physician’s order.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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 27-AS-20201218154929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: TERRACES OF ROSEVILLE, THE	FACILITY NUMBER: 312700019
	VISIT DATE: 06/03/2021

NARRATIVE

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On 3/29/2021, the Department requested for CCL Adult and Senior Care Program Clinical Nurse to review R1’s MAR. Documents revealed that the only discrepancy is for one medication that is prescribed to R1. The medication was signed off by facility staff which attest that the medication was given to R1. However, in the Medication Notes dated 11/23/2020 and 11/25/2020 stated medication was refused by R1.

The Department interviewed previous Executive Director, Jasmine Ridenour, regarding facility’s medication refusal policy. Jasmine indicated that when a Med-Tech pops medication from bubble pack to distribute to resident in care they must sign for that medication as it cannot be returned to the packaging even if the resident refuses medication.

The Department has recommended for the facility to not sign off on resident’s MAR if the medication was not given to resident as they are refusing it. Please indicate in the Medication Notes and state clearly that resident is refusing medication.

Due to the information CCL finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means 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.

A copy of this report will be provided electronically to Executive Director, Ryan Mussato, via email. ED to return a signed copy to CCL, a signed copy should be retained for facility records.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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