312700019-6-9-2022-25-AS-KHOS-CFKN3E-20220620100613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700019
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:01:23 PM

Unsubstantiated

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
02/02/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220202160729

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: 141	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Nathan Condie		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident sustained fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 06/09/2022 to deliver findings for a complaint Community Care Licensing (CCL) received on 02/02/2022. LPA met with Executive Director (ED), Nathan Condie, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn N-95 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’s report, preplacement appraisal, service plan, medical discharge documents, physical therapy evaluation documents, and unusual incident/injury report.

Continue on page LIC9099-C.

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: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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 25-AS-20220202160729

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: 06/09/2022

NARRATIVE

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On 01/24/2022, the facility submitted an unusual incident/injury report to CCL for review. The incident report indicated, on 01/21/2022 at approximately 1700 hours R1 fell in the dining room while transferring chair back to R1’s wheelchair. R1 was transported to Sutter Roseville Medical Center hospital for further evaluation and treatment. R1 was discharged back to the community with no new orders. Interview statement received from staff (S1) indicated, R1 is transferred out of chair usually by standing and grabbing onto table. The wheelchair was not pushed in enough and R1 fell when trying to grab on the table. There was no loss of consciousness or head trauma.

The Department had requested for R1’s medical records for review. On 01/22/2022, R1 was discharged from the hospital and was diagnosed with mild to moderate T12 compression fracture. No evident of significant bony canal stenosis. Mild subcutaneous fat stranding seen in the upper left buttock. Osteopenia is noted and degenerative changes are seen throughout the spine. On 01/23/2022, R1 was admitted to Kaiser Permanente Roseville Medical Center due to pain. R1 had X-Rays taken and it was discovered that R1 had a nondisplaced bilateral sacral ala fracture. On 01/25/2022, R1 was discharge from Kaiser.

The Department reviewed R1’s physician’s report and level of care assessment. According to R1’s physician’s report, R1 is able to independently transfer to and from bed. According to R1’s level of care assessment which was completed on 02/20/2020 indicates under transfer ability, R1 requires no assistance with transfers. According to Resident Care Coordinator (RCC) Kristina Waldlow, R1 is stand by assist for transfer only. Based on R1’s assessments resident is considered a fall risk and facility took the appropriate measures to provide timely medical attention to R1.

This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

An exit interview conducted.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/02/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220202160729

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: 141	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Nathan Condie		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Unlawful eviction.

INVESTIGATION FINDINGS:

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Unfounded

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: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220202160729

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: 06/09/2022

NARRATIVE

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On 01/21/2022 at approximately 1700 hours R1 fell in the dining room while transferring chair back to R1’s wheelchair. R1 was transported to hospital for further evaluation and treatment. Interview statement received from R1’s Responsible Party (RP) indicated, R1 was at a Skilled Nursing Facility (SNF) for a short period of time. An evaluation with Kaiser’s liaison and the facility’s Licensed Vocational Nurse (LVN) was conducted which indicated resident can return to the community. It was discovered through interviews that R1’s RP did not receive an eviction notice or any type of notice that R1 cannot return to the community.

The Department conducted interviews and gather statement from Resident Care Coordinator (RCC), Kristina Waldlow. According to RCC, there was no contact from SNF discharge of R1. RCC would be the one to refuse residents return due to prohibited conditions, no such refusal occurred. SNFs try to refer to six (6) beds “often”, telling residents and families that they get more individual attention at smaller facilities. R1 will likely be appropriate to return if they and the family choose to. Reappraisal scheduled with SNF for Monday 02/7/2022 and returned participated.

This agency has investigated the complaint alleging, unlawful eviction. The Department have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

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