317000237-9-26-2024-59-AS-KHOS-D9LNLU-20240930103409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317000237
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:11:43 AM

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
07/29/2024 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20240729103359

FACILITY NAME:	OAKWOOD VILLAGE, INC.		FACILITY NUMBER:	317000237
ADMINISTRATOR:	CATHY DUSTIN		FACILITY TYPE:	740
ADDRESS:	3388 BELL ROAD		TELEPHONE:	(530) 889-8122
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	124	CENSUS: 40	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Patty Uclaray, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff do not keep the facility free from infestation
Staff altered a report involving a resident
Staff did not properly report an incident involving a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Patty Uclaray during today’s inspection.
LPA investigated the allegation, “Staff do not keep the facility free from infestation”. LPA interviewed residents and staff and obtained facility documentation. Administrator stated there is construction occurring close by and so they have seen an increase in pests at the facility. Administrator stated they have a pest control company that comes to the facility several times a month to take care of any pest issues. LPA interviewed 4 residents in care in which they stated they do not see a pest issue at the facility.

Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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 4

Control Number 59-AS-20240729103359

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: 09/26/2024

NARRATIVE

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LPA interviewed staff in which they stated if they see any pests, the pest control company will come to the facility and take care of the issue. LPA toured the facility which included resident rooms and common areas and did not observe any pest infestation. Due to the information gathered LPA finds that the allegation is unfounded.

LPA investigated the allegation, “Staff altered a report involving a resident”. LPA interviewed residents and staff and reviewed facility reports. LPA interviewed staff in which they stated when an incident occurs the med tech writes a report and then sends the information to management. The management team reviews the information and creates an incident report. Staff interviews indicate that they are not aware of a time when staff have altered a report. Relevant party indicated that a report was altered by management however no specific information was provided. LPA reviewed facility incident reports and found no false information on the documentation that was reviewed. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated the allegation, “Staff did not properly report an incident involving a resident.” LPA interviewed staff and reviewed facility information. LPA interviewed staff in which they stated when an incident occurs the med tech writes a report and then sends the information to management. The management team reviews the information and creates an incident report. Administrator stated if needed then management will send incident report into CCL. Administrator stated that all medication errors are reported into CCL. Relevant party indicated that a medication error occurred, and no report was made, however no specific information was given. LPA reviewed incident reports sent into CCL and found facility is sending in incident reports throughout the year on incidents that have occurred with residents in care. Due to the information gathered LPA finds allegation to be UNFOUNDED.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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
07/29/2024 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20240729103359

FACILITY NAME:	OAKWOOD VILLAGE, INC.		FACILITY NUMBER:	317000237
ADMINISTRATOR:	CATHY DUSTIN		FACILITY TYPE:	740
ADDRESS:	3388 BELL ROAD		TELEPHONE:	(530) 889-8122
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	124	CENSUS: 40	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Patty Uclaray, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff left a resident unattended
Staff mishandled a resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Patty Uclaray during today’s inspection.
LPA investigated allegation, “Staff left a resident unattended.” LPA interviewed resident’s and staff and obtained facility documentation. Relevant party indicated there was a resident that had a fall and was left on the floor for a significant amount of time. LPA interviewed 4 residents in care in which they stated staff respond quickly when they push their pendants. 2 of 4 residents have had a fall and when they pressed their pendent for help, staff responded quickly and did not leave them alone. LPA interviewed 6 staff members in which they stated they are not aware of a resident falling and being left alone on the floor for a significant amount of time.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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 4

Control Number 59-AS-20240729103359

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: 09/26/2024

NARRATIVE

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Staff stated when a resident falls, the protocol is to call a med tech and the emergency services. Resident is never left alone when they have been found on the floor. Due to the information provided, LPA finds the allegation to be UNSUBSTANTIATED.

LPA investigated allegation, “Staff mishandled a resident's medication”. LPA interviewed residents and staff and reviewed resident medication and documentation. LPA interviewed 4 residents in care in which they stated they receive their medications in a timely manner and no medication errors have occurred. LPA reviewed 5 resident medications, comparing medications with physician orders. LPA observed all prescribed and scheduled medications were available to residents. LPA observed of the 5 resident’s medications that were reviewed no medication errors occurred. LPA interviewed staff, and 1 staff member stated medication errors have occurred in the past. Relevant party indicated that a resident was given the wrong medications, but no specific information was provided. Due to the information provided, LPA finds allegation to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

Exit interview was conducted and copy of report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4