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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001713
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:27:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240805100937
FACILITY NAME:DIAMOND OAKS RESIDENTIAL CAREFACILITY NUMBER:
315001713
ADMINISTRATOR:BUDAC, ABIGAILAFACILITY TYPE:
740
ADDRESS:501 BUTLER COURTTELEPHONE:
(916) 782-8177
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Abigail BudocTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not ensure sufficient care and supervision was provided to resident
Staff did not seek medical treatment in a timely manner for resident in care
INVESTIGATION FINDINGS:
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On 10/1/24, Licensing Program Analyst (LPA) Kevin Mknelly, arrived to deliver complaint findings and met with Abigail Budoc .

On 8/5/24, the department received a complaint regarding R1, fall on 8/4/24, alleging Staff did not ensure sufficient care and supervision was provided to resident and Staff did not seek medical treatment in a timely manner for resident in care. Additionally, on 8/5/24, the department received an incident report, from the Administrator, for the same incident.

The incident report stated that after the Administrator left the facility, R1 had a fall and appeared to hit their head. The caregiver, S1, noticed bleeding from where R1 had hit their head. S1 moved R1 to a comfortable position and attempted to call Hospice to report the fall/ injury. While S1 was attempting to call hospice, family of R1 arrived, as R1 was “bleeding slightly”, family of R1 called 9-1-1.
Report continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 6
Control Number 59-AS-20240805100937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND OAKS RESIDENTIAL CARE
FACILITY NUMBER: 315001713
VISIT DATE: 10/01/2024
NARRATIVE
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On 8/7/24, Licensing Program Analysts (LPAs) Kevin Mknelly and Graham Gunby, interviewed the Administrator, Abigail Budoc who told LPAs that Administrator had recently left the facility and had an appointment at 4 PM. Administrator stated that they had been told by the hospice agency to always call them first for resident concerns. Administrator acknowledged that they also trained S1 to this practice. The Administrator understood from their interview with S1 following the fall, that S1 heard R1 fall at approximately 4:30 PM on 8/4/24. S1 went to R1 immediately. Administrator told LPAs that S1 left R1 in the position R1 had fallen and that when family arrived, they moved R1 to a sitting position on the floor against R1’s bed.

LPAs, accompanied by Administrator, observed the placement of R1’s bed, a walker, a commode in R1’s room and the dresser on which R1 had hit R1’s head when R1 fell. Administrator stated that R1 needed cues to use their walker and that R1 independently used the commode when needed (approximately 5 feet from R1’s bed to the commode). It is unknown if R1 had used their walker. From R1’s reported potion on the floor, R1 may have fallen from near the commode to R1’s right and R1 hit their head on the dresser 4-5 feet to R1’s right.

LPAs interviewed S1 on 8/7/24. S1 reported that Administrator had worked at the facility in the morning. S1 was the lone caregiver, for three residents, at the time of R1’s fall. S1 stated that they had observed R1 to be sitting up on R1’s bed as S1 went to another resident’s room adjacent to R1’s. S1 heard a loud noise from R1’s room and immediately went to R1. R1 appeared to be in the process of removing their pants at the time of their fall on 8/5/24. R1 was found on the floor and bleeding from a laceration to R1’s head. S1 stated they moved R1 to sitting on the floor by R1’s bed and applied ice and a cloth to R1’s head injury. S1 showed LPAs S1’s phone that showed S1 attempted to reach hospice and the administrator by phone and text between 4:29 PM on 8/4/24 and 5:09 and that Admin responded by text at 5:47. S1 stated that prior to this incident, S1 had been directed that when incidents happen to residents on hospice, staff are to call Hospice instead of 9-1-1.

Report continued

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20240805100937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND OAKS RESIDENTIAL CARE
FACILITY NUMBER: 315001713
VISIT DATE: 10/01/2024
NARRATIVE
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Hospital records received by the department for R1’s hospitalization noted:
R1 arrived at an area hospital at 6:10 PM on 8/4/24.
Emergency Department records listed R1’s active problem list as: Fall in elderly patient, overactive bladder, dementia, hearing impairment, scalp laceration, head trauma and spine fracture T7 and L4. The report further notes a Large scalp hematoma.
Radiology impression lists:
1. No acute fracture or traumatic malalignment within cervical spine.
2. There may be a horizontal fracture across T7 vertebral body. Age indeterminate anterior wedge of T8.
3. Acute L4 vertebral body compression fracture with mild height loss and minimal posterior retropulsion.
4. Degenerative findings as delineated, including possible severe spinal canal narrowing at L5/L5.

R1’s laceration and treatment were described as laceration to the posterior occiput… Multiple stables placed to facilitate homostasis…Unable to sufficiently approximate wound due to underlying hematoma.

Records review- The last LIC 602- Physician’s report was for an exam on file for R1 that occurred on 1/31/24. This report noted R1 to have mild cognitive impairment, to be ambulatory, have an overactive bladder and to be in good health. R1 was enrolled in Hospice care in June-July 2024. LPAs requested hospice care documents. Hospice records were not available from the facility. The department is in process of requesting copies. LIC 602, 8/5/24, lists dementia.

Based on the evidence found in this investigation, the department finds that the allegations of Staff did not ensure sufficient care and supervision was provided to resident and Staff did not seek medical treatment in a timely manner for resident in care are substantiated. R1 was known to need assistance with ambulation. S1 last saw R1 sitting on the side of their bed yet did not intervene to assist R1 to

Report continued

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20240805100937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND OAKS RESIDENTIAL CARE
FACILITY NUMBER: 315001713
VISIT DATE: 10/01/2024
NARRATIVE
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ambulate to a commode. When R1 fell, S1 reached out to Hospice and the Administrator rather that 9-1-1 resulting in a time lapse from 4:29 PM on 8/4/24 until admitted to the emergency room at 6:10 PM- approximately 1 hour and 40 minutes. In the emergency room, R1 was found to have significant traumatic injuries.

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.



An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility.

As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.



Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20240805100937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND OAKS RESIDENTIAL CARE
FACILITY NUMBER: 315001713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87466
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Observation of the Resident… The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met based on
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Licensee will submit a plan for the amount and frequency of current resident assistance needs as well as a LIC 500 showing staffing at a level of resident needs.
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records and interviews that found R1 required physical assist while ambulating that was not provided resulting in a fall. This posed an immediate risk to the resident.
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Type A
10/02/2024
Section Cited
CCR
87469(c)(3)
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Advanced Directives and Requests Regarding Resuscitative Measures
(c) If a resident who has an advance directive and/or request... form on file experiences a medical emergency, ...(3) Specifically for a terminally ill resident that is receiving hospice services …For emergencies not directly related to
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Licensee will submit proof of training for all staff regarding the circumstances where staff are to call 9-1-1 first before family, admin of hospice.
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the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
This requirement was not met based on records and interviews found R1 had a fall with injury and 9-1-1 services were delayed. This posed an immediate risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240805100937

FACILITY NAME:DIAMOND OAKS RESIDENTIAL CAREFACILITY NUMBER:
315001713
ADMINISTRATOR:BUDAC, ABIGAILAFACILITY TYPE:
740
ADDRESS:501 BUTLER COURTTELEPHONE:
(916) 782-8177
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 3DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Abigail BudocTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff does not ensure food of good quality is provided to residents in care
INVESTIGATION FINDINGS:
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On 10/1/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Inspections found required food present. Interviews were conducted and found insufficent evidence to substantiate the allegation.

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 with administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 6