317005900-2-10-2023-25-AS-APEZ-CP4M7U-20230216082206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:34:05 PM

Unfounded

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
10/04/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221004182219

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR:	DEBRA DUVAL		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	108	CENSUS: 83	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Assistant Executive Director: Allison Lopez		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not adhere to resident's admissions agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 02/10/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 10/04/2022. LPA met with Assistant Executive Director (AED), 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 resident’s (R1) physician's report, admission agreement, identification and emergency information, level of care assessments, medication list, medication administration records (MAR), facility resident roster, staff roster, and facility’s call logs.

Continued on page LIC-9099C.

Unfounded

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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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 25-AS-20221004182219

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: 02/10/2023

NARRATIVE

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According to complainant, facility did not adhere to R1’s admission agreement. In 2021, R1 had a fall resulting a broken back. R1 was discharge from hospital and was admitted to Meadow Oaks of Roseville. Complainant indicated facility staff did not ensure to call R1 and conduct status check on R1 two times per day per admission agreement.

The Department reviewed R1’s physician’s report. R1’s primary diagnosis is fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with routine healing. R1 is unable to bathe self, dress/groom self, and care for own toileting needs. R1 is unable to administer own prescription medications, administer own PRN medication, and store own medications. R1 is not receiving hospice care. The Department reviewed R1’s initial level of care assessment completed on 04/26/2021. R1 reside in the assisted living unit. Level of care assessment indicated R1 does not require status check. On 01/26/2023, facility conducted an update on R1’s level of care assessment due to a change of condition. Level of care assessment indicated R1 does not require additional status checks.

The Department interviewed and received statement from a total of four (4) facility staff. Interview statement received from four (4) facility staff (S) indicated R1 uses call button on a daily basis for assistance and request for PRN medication. S1 indicated staff conduct rounds every two hours to check on R1. S2 indicated caregivers and Med Techs regularly conduct status checks on R1 four times per shift.

The Department requested and reviewed R1’s call log from 09/14/2022 through 10/14/2022. According to call log, 80 events were recorded and the response time average is 7 minutes. According to R1’s MAR, PRN medication has been provided to R1 consistently from 09/14/2022 through 10/14/2022. Interview statement received from AED indicated, there is no restriction on residents using call buttons.

Interview statement received from R1 indicated, staff conducts status check on R1 frequently. R1 stated R1 uses call button for assistance and to request for PRN medication. R1 stated staff delivers food to R1’s room on a daily basis and would check on R1. R1 stated facility staff are kind and R1’s needs are being met. R1 indicated response time for call button is 5-10 minutes.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies cited during today’s visit.

Exit interview conducted.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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