315002798-5-8-2025-59-AS-MSEY-DH4VBC-20250528161720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002798
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:20:29 PM

Unsubstantiated

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
12/30/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20241230142101

FACILITY NAME:	OAKMONT OF ROSEVILLE		FACILITY NUMBER:	315002798
ADMINISTRATOR:	PARVANEH MANOUCHEHRI		FACILITY TYPE:	740
ADDRESS:	1101 SECRET RAVINE PARKWAY		TELEPHONE:	(916) 771-6700
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	120	CENSUS: 85	DATE:	05/08/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Terry Ervin, Vice President of Operations		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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-Staff mismanaged resident's medications
-Staff did not ensure resident's incontinence care needs were met resulting in an infection
-Staff did not ensure resident hygiene care needs were met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Vice President of Operations, Terry Ervin, to deliver complaint investigation findings regarding the above stated allegations.

During the course of the investigation, LPA conducted interviews, a medication count, and obtained documentation pertinent to the investigation.

On April 8, 2025, LPA conducted a medication count for residents (R9, R10, and R11), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. LPA was unable to complete a medication count for resident (R1) as they have moved out of the care home. Interviews with residents (R2, R3, R4, R6, and R7) indicated that they receive all medications as prescribed. Interviews with witness (W1) and staff (S3 and S5) indicated that medications are being given as prescribed.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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 3

Control Number 59-AS-20241230142101

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: OAKMONT OF ROSEVILLE	FACILITY NUMBER: 315002798
	VISIT DATE: 05/08/2025

NARRATIVE

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R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 required complete assistance with toileting needs and has difficulty maintaining acceptable hygiene standards. R1 required hands on assistance with all grooming and hygiene tasks. R1 required total assistance and/or an additional caregiver for all showering/bathing needs 3-4 times per week. R1 required total assistance with dressing and undressing and assistance with clothes selection 2 times per day. R1 also required hands on assistance with cleaning and/or storing dentures in appropriate container. According to the December 2024 Staff Assignments log, staff initialed each time they aided with toileting according to schedule, need and requests, as well as ordering and maintaining inventory of incontinence products, clothing and linen according to need. Staff also initialed each time they aided with grooming, bathing, dressing, and denture care. The only missing entries were when R1 was hospitalized.

R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 expresses frustration or reluctance when receiving assistance with Activities of Daily Living (ADLs) but generally cooperates, minimal staff time is needed. Interviews with staff (S2) and S3 indicated that it was difficult for care staff to provide R1 assistance with ADLs. S2 and S3 indicated that R1 would become combative, however, they were still able to provide R1 care. S3 and staff (S4) indicated that, when it is difficult to provide care to a resident, the care staff team up to assist each other in providing care. W1 indicated that facility provides all care needs. R2, R3, R4, R5, R6, and R7 indicated that they are receiving assistance with all their care needs from facility staff.

Home Health Nurse indicated that R1 didn't seem unkept. Home Health Nurse indicated that they never conducted a urine analysis when R1 resided at the facility. According to facility Charting Notes, R1 was sent to the hospital on December 9, 2024, returning the same day with a UTI and a prescription for antibiotics. Emergency Department records, dated December 9, 2024, indicated that R1 sustained a fall at the facility. Records indicated that there was no evidence of injury, however, they were awaiting urine analysis results for suspected UTI. Records indicated that an antibiotic was started for potential UTI in the Emergency Department and a new prescription was ordered to continue medication upon discharge. Facility Charting Notes indicated that, on the evening of December 10, 2024, R1 had shortness of breath and was wheezing

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SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20241230142101

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: OAKMONT OF ROSEVILLE	FACILITY NUMBER: 315002798
	VISIT DATE: 05/08/2025

NARRATIVE

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so was sent to the hospital. After Visit Summary, dated December 15, 2024, indicated that R1 was admitted on December 10, 2024, and discharged on December 15, 2024. R1 was found to have COPD exacerbation with associated severe sepsis. R1 was started on additional medication. Upon discharge from the hospital, R1’s COPD exacerbation and associated severe sepsis had resolved.

Based on medication count, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

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