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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001713
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:22:20 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
01/16/2024 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240116155939
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: 4DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:caregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff restrained resident
Staff prohibited resident visits
INVESTIGATION FINDINGS:
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On 2/21/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke toIldiko Soropan, lead caregiver, to deliver complaint findings for the above allegation. The administrator arrived to assist.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Staff restrained resident- Statements by the licensee, caregiver (S1), family and hospice all found that a weighted blanket was used with R1 which was tucked and tied in place to limit R1’s movements and try to reduce R1’s restless agitation. This was not discussed with hospice or family as a viable strategy and when found by hospice, it was discontinued. This constituted a restraint by S1 of R1.

Staff prohibited resident visits- Family statements and hospice records found that family and some hospice personnel were at times discouraged from visiting or visits by appointment were enforced.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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 5
Control Number 59-AS-20240116155939
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: 02/21/2024
NARRATIVE
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There was no record of R1 expressing that they did not wish to have the visits, have visits scheduled or not enjoy the visits when they occurred.

Facility staff stated that following visits, R1 at times would have increased agitation.
The issue was not discussed and included in the hospice plan of care.


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 with the licensee . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240116155939
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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
87608(a)(5)
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Postural Supports (a) … Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
This requirement was not met based on statements. This posed an immediate risk to
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The use of the blanket was discontinued.

Licensee will remove the weighted blanket from the facility unless/ until the is a written order for it's use.
Licensee will provide staff training from a
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resident personal rights.
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hospice nurse regarding postural supports and personal rights.

licensee will submit a statement that the blanket was removed and when the training is scheduled (training within 2 weeks), by the poc date of 2/22/24.
Type B
03/06/2024
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities (a)(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Licensee will retrain staff regarding visitation rights and when it can be limited.

Proof of training to be submitted by the POC date of
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This requirement was not met based on statements that at times visits were discouraged for visits that may upset the resident.
This posed a potential risk to resident personal rights.
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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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
01/16/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240116155939

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: 4DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:caregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff mismanaged resident medication.
Staff did not ensure that resident was adequately fed
INVESTIGATION FINDINGS:
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On 2/21/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with licensee.

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

Hospice staff stated that no irregularities in verbal reports or refill requests occurred to indicate that medications were not dispensed as prescribed.

Hospice general guidance for resident food options are for the resident to determine if and how much food to consume. While facility staff offered pureed foods to R1, records did not indicate that R1 stated a preference for other foods or that hospice directed staff to prepare other foods.
R1 did have an order for thickened liquids for dysphagia but not for pureed foods.
Licensee was advised to work closely with the resident, family and hospice to provide food choices that best meet the resident’s wishes.

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:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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 5
Control Number 59-AS-20240116155939
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: 02/21/2024
NARRATIVE
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Licensee was advised to work closely with the resident, family and hospice to provide food choices that best meet the resident’s wishes.

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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5