312700019-6-3-2021-27-AS-APEZ-C42TNR-20210616145308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 06/03/2021
Date Signed: 06/03/2021 12:39:48 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:	12:31 PM
MET WITH:	Ryan Mussato		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not notify resident's responsible party of missed medication.

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 notify resident’s responsible part of missed medication.

******************************************** Continue on page LIC9099C **********************************************

Substantiated

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)

Page: 1 of 3

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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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.

Interview with previous Executive Director, Jasmine Ridenour, revealed that it is best practice to notify the resident’s Primary Care Physician (PCP) and Responsible Party (RP) for any refused medication. The Department requested for communications with R1’s RP and PCP. The facility was unable to locate and submit documentation to CCL for review. Executive Director, Jasmine Ridenour, stated Residential Care Director (RCD) will be conducting an in-service to remind Med-Techs of their standard practice to notify resident’s RP and PCP if a resident refuses a medication.

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 will be sent via email to Executive Director, Ryan Mussato, and a signed copy is to be returned to LPA.

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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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of occurrence... (D) Any incident which	1 2 3 4 5 6 7	Administrator agrees to conduct training with all staff on reporting requirements. Subject of training and staff sign in sheet to be sent into CCL by due date, 6/11/2021.
	8 9 10 11 12 13 14	threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by: Based on interviews and records reviews Administrator was unable to provide proof of facility's communications with R1's RP and PCP.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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