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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 12/08/2022
Date Signed: 12/08/2022 09:58:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/13/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220413110121
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 61DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Assistant Exectuive Director- Allison Lopez TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident is not changed and bedroom smells of urine.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 12/08/2022. LPA met with Resident Care Director, Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was 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 residents’ physician's report, level of care assessments, medication administration record (MAR), and medication list.

Continued on page LIC-9099C.
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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 8
Control Number 25-AS-20220413110121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/08/2022
NARRATIVE
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On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. According to R1’s level of care assessment, R1 needs assistance with grooming, bathing, dressing, eating, medications, and toileting. R1 is on hospice but does not require additional staff involvement. R1 requires a status check 4-6 times per day. House keeping is required daily (bed making or minor tidy up such as emptying trash). R1 also requires additional laundry 2 times weekly.

On 04/19/2022, LPA Keosavang toured the Memory Care Unit (the Villa) with Executive Director, Debra Duval. The facility has two (2) Memory Care Unit, and the Villa is a separate building which has a total of 12 residents’ bedrooms. LPA Keosavang observed a total of three (3) bedrooms in the Villa. During the tour, LPA observed R1’s bedroom has strong urine odor.

On 10/19/2022, LPA Keosavang conducted interviews and gathered statement from facility staff. Interview statement received from S1 indicated, R1 requires assistance with toileting and that R1 would try to independently use the toilet on his or her own. R1 would defecate and urinate on self. Facility care staff would assist R1 in changing into new clothes. After assisting R1 with change into clean clothes staff would remove filthy clothes from room and put them in the laundry room. Interview statement received from S2 indicated, there has been a time where staff did not change R1 during a shift change. S2 conducted rounds during start of shift and observed R1’s incontinence brief were soiled and have not been changed. S2 mentioned it to staff that was working on the earlier shift and offered to assist. S2 stated, R1 had many incidents where R1 would stand up and urinate on the floor. After assisting R1, filthy clothes may not have been put in the laundry room and washed immediately which may cause the strong urine odor in R1’s room.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

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

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20220413110121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.
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Resident Care Director agrees to maintain all incontinence resident bedrooms to be free of odor. RCD agrees to review
section 87625 and submit letter of understanding to CCL by POC due date.

On 12/14/2022, LPA amended LIC 90999-D.
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This requirement is not met as evidenced by: Based on interviews and observation the licensee did not ensure R1’s room is free of odor which poses a potential health and safety risk to 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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/13/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220413110121

FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 61DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Assistant Exectuive Director- Allison Lopez TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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- Resident not re-evaluated for change of condition.
- Resident did not receive medical attention.
INVESTIGATION FINDINGS:
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On 12/14/2022, LPA arrived at the facility unnannounced and amended the report.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 12/08/2022 on to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 04/13/2022. LPA met with Resident Care Director, Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was 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 residents’ physician's report, level of care assessments, medication administration record (MAR), death report and medication list.

Continued on page LIC-9099C.
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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 8
Control Number 25-AS-20220413110121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/08/2022
NARRATIVE
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Allegation: Resident not re-evaluated for change of condition. -Unfounded

According to Complainant, prior discharge from Skilled Nursing Facility about 6-8 months ago R1 was able to walk, talk, and use restroom on their own. R1 was also able to meet their own activities of daily living (ADLs) needs. Complainant’s concern is that R1 had declined since moving to Meadow Oaks of Roseville and facility did not re-evaluate R1 for any changes in eating, walking, and slurred speech for further medical care.

R1’s admission date was on 04/30/2021, The Department requested and reviewed R1’s level of care assessments. A total of four (4) level of care assessment were conducted by Resident Care Director, Kathryn Nevin. The initial move in assessment was completed on 04/30/2021. The facility conducted a 30-day level of care assessment on 06/06/2021. On 06/06/2021, facility conducted R1’s 30-day level of care assessment. On 08/31/2021, the facility completed R1’s 90-day level of care assessment. On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. On 05/12/2022, R1 passed away and the facility submitted R1’s Death Report to CCL.

The Department interviewed and gathered statement from R1’s responsible party (RP). RP stated R1 is 97 years old and health was declining due to old age. RP stated the facility is very communicative and often would notify RP regarding R1’s change of condition. RP stated the facility had re-evaluated R1’s change of condition multiple times. RP had to sign off on the re-evaluation, fees were updated, and adjusted based off the assessments.

The Department received R1’s Vitas Team Telecare admission orders/ hospice certification and initial plan of care for review. On 12/16/2021, R1 was placed on hospice. The facility did their due diligence by re-evaluating R1 when there was a change of condition and initiated hospice.

Allegation: Resident did not receive medical attention. – Unfounded.

According to Complainant, R1 did not receive medical care for change of condition. Complainant expressed concerns regarding R1’s abilities to conduct their own activities of daily living (ADL). Prior to R1 moving into the facility R1 was able to conduct their own ADL. After R1 moved into the facility R1 showed signs of decline in eating, walking, and slurred speech.

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20220413110121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/08/2022
NARRATIVE
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According to R1’s initial move in level of care assessment, R1 needs assistance with grooming, bathing, medications, and housing keeping. On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. According to R1’s level of care assessment, R1 needs assistance with grooming, bathing, dressing, eating, medications, and toileting. R1 is on hospice but does not require additional staff involvement. R1 requires a status check 4-6 times per day. Housekeeping is required daily (bed making or minor tidy up such as emptying trash). R1 also requires additional laundry 2 times weekly.

The Department interviewed and gathered statement from Memory Care Director (MCD), Kathryn Nervin. MCD stated R1 had a change of condition. R1 was not eating, walking, and had slurred speech. MCD indicated that R1’s decline is due to further Dementia and confusion. R1 was not gaining any weight and it was a concern. Hospice was initiated.

The Department interviewed and gathered statement from R1’s responsible party (RP). R1 stated the facility staff observed R1’s decline in health then acted by providing medical attention and notified all R1’s RPs. R1’s RP indicated that the facility had initiated hospice once R1 showed signs of declining. The Department request for R1’s hospice documents for review. On 12/16/2021, R1 was placed on hospice due to a change of condition.

Based on information above, department concluded that all these allegations are UNFOUNDED, A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

No citations were issued today. Exit interview conducted and copy of report provided.

On 12/14/2022, LPA arrived at the facility and amended the report.

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/13/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220413110121

FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Assistant Exectuive Director- Allison Lopez TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident is over medicated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 12/08/2022 on to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 04/13/2022. LPA met with Resident Care Director, Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was 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 residents’ physician's report, level of care assessments, medication administration record (MAR), death report and medication list.

Continued on page LIC-9099C.
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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20220413110121
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/08/2022
NARRATIVE
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Allegation: Resident is over medicated. – Unsubstantiated.

The Department requested and received R1’s hospice medical list and medication administration record (MAR) from the facility. The Department reviewed the medication list matches the MAR from the facility. There were no discrepancies observed. The Department request for R1’s hospice documents for review. On 12/16/2021, R1 was placed on hospice due to a change of condition.

The facility provided R1’s hospice nurse’s email address. On 11/01/2022, LPA reached out to hospice nurse via email and requested for a telephone call to gather additional information to help with the investigation. LPA did not receive a response from hospice nurse. On 11/02/2022, the Department reached out to R1’s hospice home health (Vitas Team Telecare) and requested to speak to R1’s hospice nurse. LPA spoke to team manager who confirmed hospice nurse provided care to R1. Team manager stated she will provide LPA’s contact information to hospice nurse. Team manager stated she cannot provide LPA nurse’s contact information. LPA was unable to interview hospice nurse regarding alleged allegation.

On 10/19/2022, the Department interviewed and received statements from two (2) facility staff. Interview statement received from Memory Care Director (MCD), Kathryn Nervin, indicated that the medication provided to R1 are orders for hospice patients. Interview statement received from Assistant Executive Director (AED), Allison Lopez, stated standard medications were provided to R1. Medications provided to R1 are medication that are usually prescribed to hospice residents.

On 11/29/2022, the Department conducted interview with R1’s RP. According to RP, R1’s Primary Care Physician prescribed medication that was the lowest dosage for R1. The facility and hospice home health has the medication list for R1. RP does not have any knowledge of the facility staff giving medication that was not on the list to R1 or R1 being over medicated.

Due to the information above, CCL 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8