312700019-8-12-2021-25-AS-MSEY-C5UPGG-20210813111817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 08/12/2021
Date Signed: 08/12/2021 02:55:37 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
04/15/2021 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210415102205

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: 130	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ryan Mussata		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not providing adequate care and supervision to residents.
Facility has insufficient staffing.
Staff did not provide adequate food service to residents.

INVESTIGATION FINDINGS:

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On 8/12/21 at 1:20 PM, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit and met with Interim Executive Director (ED), Ryan Mussata. Prior to initiating the complaint visit, LPA 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. LPA completed a facility risk assessment upon arrival at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPA was screened by receptionist.

On 4/15/21 the department received complaint number 25-AS-20210415102205 with the allegations sited above.
The department conducted an investigation beginning on 4/16/21 and concluding on 8/12/21.
During the investigation extensive interviews were conducted with seven (7) residents and six (6) staff, inspections were conducted on three occasions and relevant facility, resident and staff records were reviewed.
LPA finds that the allegations cited above are substantiated.
See continuation pages.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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 8

Control Number 25-AS-20210415102205

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: 08/12/2021

NARRATIVE

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The allegations of staff are not providing adequate care and supervision to residents, facility has insufficient staffing and not providing adequate food service are interrelated in this instance and though all three are substantiated allegations they warrant only one (1) citation.

Six (6) of six (6) staff interviewed acknowledged that the facility has been experiencing staff shortages for the past several months which requires the use of overtime by regular staff and use of temporary staff from an area agency. The facility continues to recruit and hire additional staff throughout this period. Three (3) of seven (7) residents expressed having experienced wait times in excess of one hour in response to the use of their pendant. R1, as reflected in the facility’s Device Activity Report, 6/22/21-7/22/21, shows 42 instances of call response times for a resident with a known heart condition. Three (3) staff reported that residents who depend on staff for activities of daily living have experienced delays or lack of assistance at times for escorts, incontinence care, transfers or dressing on those days when scheduled staff did not work.
The Interim Executive Director was advised to obtain and augment as needed staff training records for “agency staff” to ensure training requirements and that staff are competent for the assistance provided to residents.

Interviews with facility management found that in addition to shortages experienced for care staff, the facility has also undergone shortages of food service and serving employees. Four of seven residents reported long wait times for meals, meals, at times, arriving cold, meals not being what was requested and R1 experienced one day where they reportedly did not receive two meals.

See continuation pages.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 8

Control Number 25-AS-20210415102205

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: 08/12/2021

NARRATIVE

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The facility has instituted buffet service to reduce the number of servers needed and instituted Covid-19 mitigation compliant seatings to reduce the number of meals to be served to resident rooms. The facility also continues to rigorously attempt to recruit new staff.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 25-AS-20210415102205

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: 08/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.	1 2 3 4 5 6 7	Interim Executive Director reports that past staffing shortages have been corrected and that hiring/ recruiting is improving. Licensee will submit a written plan of correction to address the following areas: Augment agency staff training to be Title 22 compliant for licensed care; Modify food delivery to reduce time for
	8 9 10 11 12 13 14	This requirement is not met based on records and statements that found delays and, at times, delayed or missed ADLs and delayed or missed meal due to insufficient staff. This posed an immediate risk to residents health and safety.	8 9 10 11 12 13 14	delivery and ensure foods are maintained in safe temperatures; and The facility's will submit a plan to monitor and respond timely with procedures for residents' calls for assistance. This plan of correction will be submitted to CCL by the POC date of 8/26/21.
	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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 8

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
04/15/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20210415102205

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:	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:			TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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-Resident sustained a death while in care.
-Residents are not being reappraised as necessary.
- Staff are yelling at residents while in care.
- Facility has inadequate record keeping.

INVESTIGATION FINDINGS:

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On 8/12/21 at 1:20 PM, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit and met with Interim Executive Director (ED), Ryan Mussata. Prior to initiating the complaint visit, LPA 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. LPA completed a facility risk assessment upon arrival at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPA was screened by receptionist.

On 4/15/21 the department received complaint number 25-AS-20210415102205 with the allegations sited above.
The department conducted an investigation beginning on 4/16/21 and concluding on 8/12/21.
During the investigation extensive interviews were conducted with residents and staff, inspections were conducted on three occasions and relevant records were reviewed.
LPA is unable to find and or meet the preponderance, per policy.
See continuation pages.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 25-AS-20210415102205

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: 08/12/2021

NARRATIVE

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The allegation that a resident sustained a death while in care is true in that residents at the facility have passed away. The allegation, however, did not specify a specific resident nor a time period. The investigation was therefore unable to find sufficient evidence.
The allegation that residents are not being reappraised as necessary was vague. The example provided was related to residents safely managing motorized scooters. Residents who’s abilities are in question will be reassessed. The investigation was therefore unable to find sufficient evidence.
The allegation of staff are yelling at residents while in care. Was specific to one employee who is no longer employed. Many staff who worked at that time are also unavailable. Residents and staff who have been at the facility during the time in question had not witnessed such behavior or heard of such behavior.
The allegation of facility has inadequate record keeping was also vague in specifics or records or timelines. Records reviewed did not find them to be inadequate. The investigation was therefore unable to find sufficient evidence.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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.

Exit interview conducted and report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 8

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
04/15/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20210415102205

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:	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:			TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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On 8/12/21 at 1:20 PM, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit and met with Interim Executive Director (ED), Ryan Mussata. Prior to initiating the complaint visit, LPA 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. LPA completed a facility risk assessment upon arrival at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPA was screened by receptionist.

On 4/15/21 the department received complaint number 25-AS-20210415102205 with the allegations sited above.
The department conducted an investigation beginning on 4/16/21 and concluding on 8/12/21.
During the investigation extensive interviews were conducted with residents and staff, inspections were conducted on three occasions and relevant records were reviewed.
LPA finds that facility met Tittle 22 requirements.
See continuation page.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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 8

Control Number 25-AS-20210415102205

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: 08/12/2021

NARRATIVE

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Facility inspections and interviews found the facility to be clean and well maintained.
LPAs observed some equipment in the kitchen which is inoperable (the gas oven), yet alternative equipment as available and operational for safe and sanitary food preparation and storage.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview with Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 8