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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 12/02/2021
Date Signed: 12/02/2021 03:41:04 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
10/26/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201026091059
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: 41DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Debra Duval TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Lack of supervision resulting in resident wandering away from the facility.
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 a complaint finding for a complaint Community Care Licensing (CCL) received on 10/26/2020. LPAs met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPAs 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 arrive at the facility and completed a facility risk assessment. LPAs 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 relevant to the allegation: lack of supervision resulting in resident wandering away from the facility. The Department received R1’s Physician’s Report, Level of Care Assessment, Medication Administration Records, Admission Order, Progress Notes, and Preplacement Appraisal Information.

*************************************** Continue on page LIC 809-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: 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)
Page: 1 of 5
Control Number 27-AS-20201026091059
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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According to Complainant, R1 was admitted into the assisted living side of the facility beginning of August 2020. The 3rd week of August, R1 was able to leave the facility and did not notify facility staff. After the incident R1 was transferred to the memory care side to make sure there was more supervision for R1. R1 was able to leave the facility again without staff’s knowledge. Complainant had to call the facility to notify them that R1 had left the facility.

Records review revealed, on 08/03/2020 an initial level of care assessment was completed by the facility. It was discovered, R1’s elopement history and concerns were reviewed by facility’s Resident Care Director (RCD). On 09/07/2020, a second level of care assessment was completed by the facility due to R1 being moved to Memory Care Unit. The level of care assessment states that R1 requires staff to escort up to 3 times daily and requires checks at regular interval. On 10/02/2020, a third level of care assessment was completed by the facility. Changes in the level of care assessment indicated an increase in R1’s required checks at frequent intervals.

The Department interviewed and received statement from Resident Care Director (RCD), Allison. RCD was asked to elaborate on R1’s level of care assessment which states that R1 requires staff to escort up to 3 times daily. RCD stated R1 is being escorted to breakfast, lunch, and dinner. RCD was asked to elaborate requires checks at regular intervals. RCD stated, if resident was on status check then staff is to check on resident throughout the day and night. RCD was asked if staff is required to check on R1. RCD answered, yes.

It was discovered that on 07/29/2020, R1 moved into the assisted living unit of the facility. On 09/05/2020, R1 was moved to memory care unit. The Department reviewed facility’s communication with R1’s Physician. On 10/03/2020, the facility notified R1's Physician that R1 had left the community on 10/02/2020 at 2 PM and was taken to his former residence by a good Samaritan. R1 was transported back to the community in good condition. No c/o pain or discomfort.



Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D.

Appeal rights provided to the facility.

An exit interview was conducted with Debra Duval, Executive Director, and a copy of this report will be provided to the facility via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (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)
Page: 2 of 5
Control Number 27-AS-20201026091059
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided ... that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Executive Director agrees to conduct staff training regarding elopment. Facility to submit scheduled training by end of day 12/3/2021. Training to be completed by all care staff by 12/31/2021.
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This requirement is not met as evidenced by: Based on records review and interviews, R1 left the facility and was driven to wife's residence by a good samaritan. This poses an immediate threat to the health and safety of the resident in care.
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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: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
10/26/2020 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201026091059

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: DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Debra Duval TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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- Staff did not notify resident's authorized representative of change in health condition.
- Staff did not seek timely medical attention for resident.
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 10/26/2020. LPAs met with Administrator, Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPAs 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. LPAs arrived at the facility and conducted risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and N-95 masks. 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 relevant to the allegation: staff did not notify resident's authorized representative of change in health condition and staff did not seek timely medical attention for resident.

*******************************************Continue on page LIC 809-C *************************************************
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: 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)
Page: 4 of 5
Control Number 27-AS-20201026091059
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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CCL received an Unusual Incident/Injury Report from the facility indicating R1 was sent to Roseville ER due to a medical emergency. On 10/13/2020, staff found R1 significantly weaker and unable to get out of chair. R1 made complaints of dizziness, difficulty breathing, and difficulty seeing. Staff called 911 at 4:10 p.m. and remained with R1 until emergency response arrived at 4:20 p.m. R1’s Responsible Party (RP) was notified. According to the facility, R1 did not return to the community and was moved to a higher level of care facility.

The facility conducted a total of three (3) Level of Care Assessments on R1. On 08/03/2020, R1’s Level of Care Assessment revealed R1 has moved into the Assisted Living Unit and does not require hospice services. On 09/07/2020 and 10/02/2020, another Level of Care Assessment was performed on R1. Documents revealed R1 moved out of the Assisted Living Unit to the Memory Care Unit. Changes in the Level of Care Assessment include the facility requiring staff to check on R1 at regular intervals due to elopement history. There is no indication on the Level of Care Assessment of change in health condition or require hospice services.

The Department reviewed the facility’s communication with R1’s Physician on 10/13/2020. Documents revealed that the reason for communication was due to R1’s change in behavior and later that day was transferred to the hospital. R1 has been very confused for the last few days. R1 was complaining about shortness of breath, not able to get put of chair, has been having delayed response to questions, and when calling R1’s name. Facility reported to R1’s Physician that R1 is not able to do something that R1 was doing before. Facility asked for R1’s Physician’s advice. Physician responded back to the facility that R1’s responsible party was notified of change of condition and 911 was to be called.

This agency has investigated the above listed allegations. 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 allegations to be UNSUBSTANTIATED.

An exit interview conducted, and a copy of the report was left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (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)
Page: 5 of 5