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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 04/26/2021
Date Signed: 04/26/2021 11:10:33 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200812142314
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:JASMINE RIDENOURFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 61DATE:
04/26/2021
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Debra Duval- AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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- Staff did not administer resident’s medication per physician’s order.
- Staff did not inform the authorized representative to renew physician's order.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 4/26/2021 to deliver complaint finding for a complaint Community Care Licensing (CCL) received on 08/12/2020. LPA spoke with Executive Director, Debra Duval, and explained the purpose of the telephone call.

Throughout the course of the complaint investigation the Department conducted interviews and obtained documents such as resident’s (R1) Medication Administration Records (MAR), Medication list, Blood Pressure Log, Physician’s Report, Level of Care Assessment, and facility’s sign in and out sheet that’s relevant to the allegation: staff did not administer resident’s medication per physician’s order and staff did not inform authorized representative to renew physician’s order.

Allegation: Staff did not administer resident’s medication per physician’s order. – Substantiated.

**********Continue on LIC9099-C ************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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 27-AS-20200812142314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 04/26/2021
NARRATIVE
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Documents reviewed revealed, facility staff did not administer R1’s medication per physician’s order on 1/3/2020, 1/13/2020, 1/18/2020, 1/25/2020, and 2/8/2020.

LPA interviewed and received statements from five (5) facility staff (S). Interview with S4, indicated that if there are no facility staff signatures on the MAR’s then most likely the medication was not given to the resident.

Medication notes was provided by facility for review. LPA reviewed medication notes and observed on the dates listed above, there are no notations or explanation to why medication was not given to R1. Facility was unable to provide documentation stating R1 had refused their medications.

LPA requested for facility’s sign in and out sheet for the month January of 2020. Document reviewed revealed, R1 did not sign out of the community on the dates listed above.

Per Facility’s Medication Policy, missed/refused medication are documented in the resident’s medication record and in resident’s care notes. The prescribing physician is notified or missed/refused medications immediately or in the time frame and according to the parameters as indicated by the physician using the Refusal of Medication Notification form. Physician parameters must be retained in writing and filed in the chart under Physician Orders. The responsible party is notified. The Resident Care Director re-appraises the resident and contacts the physician and responsible party if the resident is continually refusing a medication(s).

LPA requested for facility’s communication with R1’s Physician to notify them of missed medication per facility’s policy. Facility was unable to provide documentation for the month of January and February of 2020.

Allegation: Staff did not inform authorized representative to renew physician’s order. – Substantiated.

On 10/05/2020, LPA Keosavang and Leitzell was present at the facility to conduct interviews with facility staff and residents. LPA reviewed five resident’s files. LPAs observed that there was not a notice to resident’s (R1) authorized representative regarding renew Physician’s order for medication and blood pressure orders. Per Physician’s Order, R1 needs to take a medication that requires facility staff to monitor R1’s blood pressure to determine the amount of dosage that needs to be given. The end date in R1’s MAR for the medication was dated on 2/8/2020. After 2/8/2020, there were no communication with pharmacy, R1’s Doctor’s office, and R1’s authorized representative for new orders. LPA requested for facility’s communication with R1’s Physician and pharmacy. Facility is unable to provide documentation.

******* Continue on LIC9099-C ************

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200812142314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 04/26/2021
NARRATIVE
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LPAs interviewed and received a statement from prior Executive Director, Jasmine Ridenour. Interview with Jasmine Ridenour revealed that the facility does not usually contact the resident’s authorized representative regarding blood pressure orders because family is usually involved in R1’s wellbeing. Jasmine Ridenour stated they did not contact resident’s authorized representative of change in Physician’s order to conduct blood pressure monitoring.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report will be sent via email to Executive Director, Debra Duval, and a signed copy is to be returned to LPA.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20200812142314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care Services (a) A plan for incidental medical and dental care shall be developed by each facility. (5) the licensee shall assist residents with self-administered medications as needed.
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Administrator agrees to schedule an audit from an outside agency to audit medication rooms. Administrator to inform LPA of what agency and date the audit will take place by 4/27/2021.

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This requirement is not met as evidenced by: Based on records review and interviews, medication was not given to R1 and not documented on the Medication Administration Records per facility policy.
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Administrator agrees to conduct a training with all staff on proper medication documentation and medication management. Subject of training and staff sign in sheet to be sent into CCL by 4/27/2021.
Type A
04/27/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 (a)(8) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations,
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Administrator agrees to conduct training with all staff on reporting requirements. Subject of training and staff sign in sheet to be sent into CCL by 4/27/2021.
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as appropriate to their needs. This requirement is not met as evidenced by: Based on records review and interviews, facility did not notify the change in physician’s order.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200812142314

FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:JASMINE RIDENOURFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 61DATE:
04/26/2021
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Debra Duval- AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
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- Staff did not provide adequate food service to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 4/26/2021 to deliver complaint finding for a complaint Community Care Licensing (CCL) received on 08/12/2020. LPA spoke with Executive Director, Debra Duval, and explained the purpose of the telephone call.
Throughout the course of the complaint investigation the Department conducted interviews with seven (7) residents (R). It was discovered through interviews with R1, R2, R3, R4, and R6 that food is adequately provided, three meals a day with a range of items being served. Interviews with R5 and R7 indicated food is being served to residents on time, however; the food is not good. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the report will be sent via email to Executive Director, Debra Duval, and a signed copy is to be returned to LPA.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5