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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:03:22 PM

Unsubstantiated


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
10/13/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211013124652
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:SAMANTHA MURPHYFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 67DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Debra Duval TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Facility does not have adequate staffing to meet residents' needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 04/07/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 10/13/2021. LPA met with Executive Director (ED), 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. LPA arrived 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. Additionally, LPA were screened by facility staff upon entering the facility.

Throughout the course of the investigation, the Department conducted interviews and reviewed pertinent documentation relevant to the allegation listed above such as R1’s Physician’s Report, PRN Authorization Letter, Diet Request Form, Level of Care Assessments, Service Agreement, Admission Agreement, facility’s staff and resident rosters, and employee timecards.
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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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 4
Control Number 25-AS-20211013124652
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: 04/07/2022
NARRATIVE
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Interview statement received from Complainant indicated, the facility has only one (1) caregiver providing care to thirty (30) residents. The Department interviewed and received statements from a total of three (3) facility staff from the Memory Care Unit. Through interview statements received from facility staff it was discovered the facility had hired staffing agency to cover shifts. The Department had received and reviewed facility’s employee timecards. In September of 2021 the employee timecards display one (1), caregiver was assigned to work a shift, two (2) agency staff were paid to cover shifts, and one (1) Med-Tech is always on the floor.

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



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

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/13/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211013124652

FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:SAMANTHA MURPHYFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Debra Duval TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff are not adhering to the COVID protocols.
- Facility raised resident's rate without proper notice.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 04/07/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 10/13/2021. LPA met with Executive Director (ED), 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. LPA arrived 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. Additionally, LPA were screened by facility staff upon entering the facility.

Allegation: Staff are not adhering to the COVID protocols. – UNFOUNDED.

Throughout the course of the complaint investigation the Department conducted interviews. According to Complainant, VA Health Care worker was allowed entry into the facility without showing proof of COVID-19 vaccination.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20211013124652
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: 04/07/2022
NARRATIVE
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On 10/20/2021, the Department arrived at the facility and conducted an interview with Executive Director. It was discovered that Executive Director allowed entry to a Health Care worker without proof of vaccination. Executive Director stated that she had review the PIN 21-40-ASC and that’s why she granted VA Health Care worker entry to the community. According to PIN-40-ASC, the vaccination and testing requirements, and verification and recordkeeping conditions do not apply to: Visit from CDSS, CDPH, CDDS or local health department officials, mental/healthcare provider (e.g., home health and hospice agencies), and essential government authorities needing to enter or conduct investigations at the facility.

Allegation: Facility raised resident’s rate without proper notice. – UNFOUNDED.

According to complainant, the facility had increased R1’s rate to $1895.00 without notice. The cost of rent had been the same and consistent for 3 years. The Department had requested for the facility to provide proof of notice that was sent out to R1’s responsible party.

It was discovered that the facility sent out a notice of increase in monthly rate to R1 and R1’s responsible party on 04/22/2021. The facility stated the reason for rate increase is due to increase in food, utilities, transportation, technology, and the most impactful, an increase in labor costs. Due to these factors the facility will be charging R1 with a new rate of $5265.00. The letter states that this new rate will go into effect on 07/01/2021. R1’s responsible party had signed the agreement on 04/30/2021.

According to Title 22, modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes.

This agency has investigated the complaint allegations above. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview conducted.

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

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4