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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 12/02/2020
Date Signed: 12/02/2020 02:00:30 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200410082600
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: 65DATE:
12/02/2020
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Samantha Murphy, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility raised fees without giving proper notice to responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility via phone on 12/02/2020 due to COVID-19 and precautionary measures to deliver complaint findings for the allegations listed above, LPA spoke with Executive Director Samantha Murphy and explained the purpose of the call.

Throughout the course of the investigation Community Care Licensing (CCL) reviewed resident’s (R1) admission agreement, appraisals, re-appraisals, service agreements, invoices, as well as other documents, and conducted interviews regarding the allegation: Facility raised fees without giving proper notice to responsible party.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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 7
Control Number 27-AS-20200410082600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/02/2020
NARRATIVE
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CCL reviewed a service agreement dated 02/27/2020 for R1 and signed by R1’s responsible party on 03/01/2020, service agreement lists services and estimated monthly costs for all sections as zero. Invoice with a due date of 04/01/2020 was reviewed and revealed charges dated 03/03/2020 for assisted living level 6, prior to this R1 was being billed for Rent-AL with no assisted living level fee being charged. Notice of Increase in Monthly Rate dated 03/11/2020 with description of charges was reviewed and revealed that AL-Care Level 6 was listed on the schedule of fees to begin 05/11/2020. Documents reviewed do not reveal that R1’s responsible party was provided a written notice of rate increase after the updated service agreement was completed on 02/27/2020 but was charged a rate increase starting 03/03/2020.

Due to this information CCL finds the allegation(s) 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.

The following deficiency is cited on attached LIC 9099-D:

§1569.657 Rate increase due to change in level of resident care; notice



(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.

Exit interview conducted.

A copy of the report and appeal rights provided electronically to Executive Director via email. Executive director to return a signed copy to CCL, a signed copy should also be retained for facility records.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200410082600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2020
Section Cited
HSC
1569.657(a)
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§1569.657 Rate increase due to change in level of resident care; notice
(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services
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Licensee agrees to ensure that residents and their representatives are provided proper written notice of rate increases due to a level of care increase that includes itemization of the charges. Letter of understanding due to CCL by 12/16/2020.
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to be provided at the new level of care and an accompanying itemization of the charges.
This requirement was not met as evidenced by: documentation review. The licensee did not comply with the regulation cited above, R1's rate was increased without proper notice. This poses a potential health and safety risk to residents 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200410082600

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:
12/02/2020
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Samantha Murphy, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility charged resident for services not provided.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility via phone on 12/02/2020 due to COVID-19 and precautionary measures to deliver complaint findings for the allegations listed above, LPA spoke with Executive Director Samantha Murphy and explained the purpose of the call.

Throughout the course of the investigation Community Care Licensing (CCL) reviewed resident’s (R1) admission agreement, appraisals, re-appraisals, service agreements, invoices, as well as other documents, and conducted interviews regarding the allegation: Facility charged resident for services not provided.

Documentation reviewed and interviews conducted revealed that there were services billed for and then refunded.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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 7
Control Number 27-AS-20200410082600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/02/2020
NARRATIVE
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Due to this information CCL finds the allegation(s) to be UNSUBSTANTIATED - A finding that a complaint allegation is unsubstantiated means 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.

A copy of the report and appeal rights provided electronically to Executive Director via email. Executive director to return a signed copy to CCL, a signed copy should also be retained for facility records.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200410082600

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:
12/02/2020
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Samantha Murphy, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility did not do a reappraisal prior to raising care level fees.
INVESTIGATION FINDINGS:
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5
6
7
8
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10
11
12
13
Licensing Program Analyst (LPA) Wolter contacted the facility via phone on 12/02/2020 due to COVID-19 and precautionary measures to deliver complaint findings for the allegations listed above, LPA spoke with Executive Director Samantha Murphy and explained the purpose of the call.

Throughout the course of the investigation Community Care Licensing (CCL) reviewed resident’s (R1) admission agreement, appraisals, re-appraisals, service agreements, invoices, as well as other documents, and conducted interviews regarding the allegation: Facility did not do a reappraisal prior to raising care level fees.

Report continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200410082600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 12/02/2020
NARRATIVE
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CCL reviewed a service agreement dated 02/27/2020 for R1 and signed by R1’s responsible party on 03/01/2020, service agreement lists services and estimated monthly costs for all sections as zero. While the facility did raise care level fees on the invoice billed, a reappraisal was completed prior to doing so.

Due to this information CCL finds the allegation(s) to be UNFOUNDED - meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted.

A copy of the report and appeal rights provided electronically to Executive Director via email. Executive director to return a signed copy to CCL, a signed copy should also be retained for facility records.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7