312700602-6-16-2021-25-AS-KMKY-C47UQC-20210621154654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700602
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:59:30 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
05/25/2021 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 25-AS-20210525160045

FACILITY NAME:	OAKMONT OF ROSEVILLE		FACILITY NUMBER:	312700602
ADMINISTRATOR:	SMITH, AUSTRIA		FACILITY TYPE:	740
ADDRESS:	1101 SECRET RAVINE PARKWAY		TELEPHONE:	(916) 771-6700
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	120	CENSUS: 77	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Business Office Director, Angelique Doyle		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff failed to provide supervision which resulted in falls
Staff did not inform the authorized representative that resident fell

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 06/16/2021 to deliver complaint findings for a complaint the Department received on 05/25/2021. LPA met with Business Office Director, Angelique Doyle and explained the purpose of the visit. Prior to initiating today's inspection, 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 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

Throughout the course of the investigation, LPA conducted multiple interviews, and reviewed documentation pertinent to the allegations listed above. The results are as follows:

***Continuation on LIC9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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 25-AS-20210525160045

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: OAKMONT OF ROSEVILLE	FACILITY NUMBER: 312700602
	VISIT DATE: 06/16/2021

NARRATIVE

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Allegation(s): Facility staff failed to provide supervision which resulted in falls, Staff did not inform the authorized representative that resident fell

The complaint alleged resident (R1) occurred multiple falls while in care and the facility did not notify R1's representative. On 06/10/2021 LPA reviewed R1's records which indicate R1 "is at risk of falling and requires staff observation to promote safety." Facility records show R1 was sent to the hospital on 04/09/2021 and seen by the paramedics on 04/12/2021 due to a fall. On 06/09/2021, LPA interviewed Memory Care Director who confirmed R1 fell twice in the facility and was sent out to the hospital on 04/09/2021. Facility FAX reports dated 04/09/2021 and sent to R1's physician indicate R1's representative was notified. LPA interviewed Administrator on 05/26/2021 who stated R1's last fall was 04/12/2021 and R1 was seen by the paramedics. Administrator stated the facility notified R1's representative the day of the incident. On 05/26/2021 LPA requested incident reports to review for R1, however, the facility could not provide reports. LPA checked Community Care Licensing (CCL) electronic files and did not find any incident reports for R1. On 06/16/2021 LPA spoke with outside agency, Your Home Assistant who provided one-on-one companionship for R1 during May 2021. LPA was unable to interview care companion due to personal reasons, however LPA was able to retrieve and review care notes for R1. Care notes from Your Home Assistant indicate R1 fell once on 05/11/2021 and was seen by the facility med tech. No further evidence was provided.

LPA finds the allegations listed above to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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