317005900-7-27-2021-27-AS-KHOS-C67MFB-20210824093403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:10:18 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
01/05/2021 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210105104630

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR:	SAMANTHA MURPHY		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	108	CENSUS: 69	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator, Debra Duval		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff did not ensure resident's colostomy bag was changed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 07/27/2021 to deliver complaint findings. Prior to visit, 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; contacted licensee 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.
LPAs met with Administrator Debra Duval and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation relevant to the allegation listed above.
The results are as follows:

***Continuation on LIC9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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-20210105104630

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: 07/27/2021

NARRATIVE

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Allegation: Staff did not ensure resident's colostomy bag was changed.

Complaint alleged R1 was not receiving assistance with their colostomy bag. 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 colostomy bag. R1's care assessment conducted by the facility indicates R1 is able to self manage colostomy bag. 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.

LPA finds the allegation 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, and the findings are unsubstantiated.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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