317005900-6-16-2021-27-AS-KMKY-C48U2G-20210622151153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 06/16/2021
Date Signed: 06/16/2021 01:54:56 PM

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
10/19/2020 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 27-AS-20201019113838

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR:	JASMINE RIDENOUR		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	108	CENSUS: 63	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator, Debra Duval		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not assist a resident with hygiene needs
Staff would not allow a resident to have a visitor

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 06/16/2021 to deliver findings for a complaint the Department received on 10/19/2020. LPA met with Administrator, Debra Duval and explained the purpose of the visit. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

Throughout the course of the investigation, LPA conducted multiple interviews and reviewed documentation pertinent to the allegations listed above.
Results are as follows:

***Continuation on LIC9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201019113838

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: 06/16/2021

NARRATIVE

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Allegation: Staff did not assist a resident with hygiene need
Complaint alleged R1 was not receiving assistance with their colostomy bag, grooming or bathing. On 05/28/2021 LPA reviewed resident (R1)'s records. R1's medical assessment (dated 3/17/2020) indicates R1 is able to self manage grooming, bathing and colostomy bag. R1's care assessment conducted by the facility indicates R1 requires reminders for grooming, assistance for bathing once a week, and is able to self manage colostomy bag. On 06/09/2021 LPA reviewed R1's ADL charts for the months of August, September and October 2020, which indicated R1 received grooming reminders 4-7 times a week and two (2) baths a week. On 05/28/2021 LPA interviewed R1's spouse who stated R1 was managing their own colostomy bag and did not have issues regarding his hygiene.
On 06/08/2021 LPA interviewed three (3) of three (3) facility staff. Majority of staff stated R1 was responsible for their colostomy bag and was able to empty it themself but needed daily reminders. Due to R1's passing on 10/17/2020, LPA was unable to interview R1. No further evidence was provided.

Allegation: Staff would not allow a resident to have a visitor.
Complaint alleged staff did not allow R1 to have a visitor.
On 05/28/2021 LPA reviewed facility's visitor guidelines. Visitor guidelines indicate residents are allowed visitors under limited guidelines. On 05/28/2021 LPA observed visitor guidelines to be in compliance with PIN 20-38 ASC which covers state guidelines for facility on-site visits. On 06/08/2021 LPA reviewed facility visitor sign in sheets for the months of August, September and October 2020. LPA observed that during the months of August, September and October, R1 did not have a visitor sign in. LPA found that during the months observed other residents in care were visited by outside guests. On 06/08/2021 LPA interviewed three (3) of three (3) staff who stated the facility allows on-site visits within limited guidelines. LPA interviewed R1's family member who stated family had visited R1 in October 2020. Due to R1's passing on 10/17/2020, LPA was unable to interview R1. No further evidence was provided.

Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning 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 conducted with Administrator, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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