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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317000237
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:30:53 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221122102314
FACILITY NAME:OAKWOOD VILLAGE, INC.FACILITY NUMBER:
317000237
ADMINISTRATOR:JOHN O'BRIENFACILITY TYPE:
740
ADDRESS:3388 BELL ROADTELEPHONE:
(530) 889-8122
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:124CENSUS: 47DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cathy Dustin and Mary Roberts TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff is mismanaging resident's medications.
Staff does not ensure resident is fed.
INVESTIGATION FINDINGS:
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LPA has met with and spoken with Directors, staff, reviewed documentation, toured the facility on at least 2 occasions. No specific examples were given regarding when medications may have been given incorrectly, other than “in the morning.” LPA has reviewed medication records and interviewed staff. Complaint details stated it was thought that staff may have given R1 a particular medication (Seroquel) in the morning causing issues. (The medication was prescribed for bedtime.) However, LPA finds no evidence that there were medication errors made or medications given at incorrect times in the care of resident R1. In addition, Oakwood Village uses a computerized medication system that only allows medications to be given at certain times, etc. LPA finds there is no basis for this allegation. Allegation is Unfounded.
LPA has reviewed documentation including initial and updated assessments and spoken with staff. LPA learned that R1 liked to stay in bed in the morning and did not always want to be awakened for breakfast. Staff encouraged R1 to eat trays of food brought in by staff later, but R1 did not always want to eat. Staff cannot force a resident to eat a meal if the resident does not want to eat at that time. From reviewing staff
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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 4
Control Number 25-AS-20221122102314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: OAKWOOD VILLAGE, INC.
FACILITY NUMBER: 317000237
VISIT DATE: 05/25/2023
NARRATIVE
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notes it appears that R1 sometimes would go out to the dining room for breakfast and would eat; and would sometimes eat what was brought on a tray. However, it dos not appear that staff was in any way neglecting the nutrition of R1. Allegation is Unfounded.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221122102314

FACILITY NAME:OAKWOOD VILLAGE, INC.FACILITY NUMBER:
317000237
ADMINISTRATOR:JOHN O'BRIENFACILITY TYPE:
740
ADDRESS:3388 BELL ROADTELEPHONE:
(530) 889-8122
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:124CENSUS: DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cathy Dustin and Mary TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
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3
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5
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9
Staff left resident soiled for extended periods of time
Staff does not keep up with resident's hygiene needs.
Staff does not provide resident with clean clothing
Staff does not provide resident with hearing aid.
Staff does not communicate with resident's authorized representative of resident's change of health condition.
INVESTIGATION FINDINGS:
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LPA has reviewed documentation including resident care notes and initial and updated care plans, and spoken with staff. LPA learned that when R1 moved in to Oakwood Village the initial assessment completed with family indicated that R1 was independent with dressing and toileting, only needed to be checked twice per shift. As time went on, staff got to know R1 and learned that R1 did in fact need more assistance than originally assessed. The plan was re-written with family at that time and services were increased. Therefore, it is possible that R1 may have been found soiled, but the facility was still learning the resident’s needs. As soon as it was discovered that needs were higher services were increased. It is not possible to say if original assessment was accurate or if the functioning of R1 decreased over her stay. Therefore, allegation is Unsubstantiated.

Regarding staff not keeping up with resident's hygiene needs, as stated above in a previous allegation, R1 was assessed initially as only needing set up/standby for showers and routine care with hygiene. As staff got to know her, it was found that R1 needed more assistance than originally assessed. Therefore,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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-20221122102314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: OAKWOOD VILLAGE, INC.
FACILITY NUMBER: 317000237
VISIT DATE: 05/25/2023
NARRATIVE
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it is possible that R1 may have been found needing hygiene assistance, but the facility was still learning the resident’s needs. As soon as it was discovered that needs were higher than initially assessed, services were increased. It is not possible to say if original assessment was accurate or if the functioning of R1 decreased over her stay. Therefore, allegation is Unsubstantiated.

Regarding the allegation that Staff does not provide resident with clean clothing: As above, initial assessment stated R1 was independent with dressing. As staff got to know her, it was found she did need some assistance with dressing/reminders. Even with assistance, LPA learned that R1 would sometimes refuse to change her clothes. Therefore, it is possible that R1 may have been found in dirty clothes, but the facility was still learning the resident’s needs. As soon as it was discovered that needs were higher services were increased. It is not possible to say if original assessment was accurate or if the functioning of R1 decreased over her stay. Also, she may have been found not wearing clean clothes on a day she refused to change. Staff cannot force a resident to change. Therefore, allegation is Unsubstantiated.

Regarding the allegation that staff does not provide resident with hearing aid: LPA has reviewed documentation provided and interviewed staff. LPA learned that R1 liked to stay in bed late. LPA also learned that staff did not assist R1 with her hearing aids until she was out of bed for the day; they did not attempt to put in her hearing aids while in bed. LPA also learned that R1’s visitors sometimes arrived earlier in the morning, when R1 was still in bed. Therefore, she would not have had the hearing aids in yet. LPA is not able to say if R1 was ever out of bed for any length of time without hearing aids. However, there is no evidence to suggest that the staff were in any way “neglecting” the needs of R1. Allegation is Unsubstantiated.

Regarding the allegation that staff does not communicate with resident's authorized representative of resident's change of health condition: LPA has reviewed documentation and interviewed staff. LPA found various notes stating that the Responsible Party had been contacted regarding issues with R1 on different dates; as well as staff saying they had contacted RP. Staff interviewed stated that the contact person was the daughter, and that who they would contact. At this time it is not possible to say if staff were really aware of an issue at some point and did not contact a responsible party. Allegation is Unsubstantiated.

Appeal rights provided, exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4