317005900-12-2-2021-27-AS-KHOS-C9JPX2-20211209104137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 12/02/2021
Date Signed: 12/02/2021 03:37:55 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
12/17/2020 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201217161702

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: 70	DATE:	12/02/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Debra Duval		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident obtained a pressure injury at facility due to neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Sarena Keosavang and Melissa Parks arrived at the facility unannounced on 12/02/2021 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 12/17/2020. LPA met with Administrator, Debra Duval, and explained the purpose of the visit. Prior to initiating the 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 and LPAs arrives at the facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and N-95 Mask. Additionally, LPAs were screened by facility staff upon entering the facility.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents such as resident's (R1) physician's report, level of care assessment, medical discharge paperwork, outside home health agency ntoes, and communication logs relevant to the allegation: Resident obtained a pressure injury at facility due to neglect.

******************************************* Continue on page LIC-809C *************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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-20201217161702

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: 12/02/2021

NARRATIVE

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Records review revealed, R1 has a history of skin integrity. It was discovered that R1 was ambulatory, independent, and was able to perform most ADLs. LPA was unable to find any documentation related to any pressure injury. Specifically, Home Health Nurse documentation revealed that no wound could be found 5 days after hospital discharge.

Staff interviews conducted revealed that R1 had a history of dry skin and rash which was being treated by prescription ointment. Staff interviews did not reveal any history of wounds or issues with skin integrity due to neglect. LPA interviewed R1's POA who acknowledged that R1 had a history of skin issues and skin tears due to skin fragility. LPA additionally interviewed R1's assigned Home Health Nurse who acknowledged that R1 was mostly independent of ADLs, active, and never observed any pressure injuries.

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 Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC9099 (FAS) - (06/04)

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