317005900-9-14-2023-59-AS-KHOS-CVSREE-20230918125726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:32:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230510083840

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR:	NATHAN CONDIE		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	108	CENSUS: 89	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Assistant Exectuive Director: Allison Lopez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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- Staff did not provide incontinence care in a timely manner.
- Staff did not attend to resident who was vomiting in a timely manner.
- Staff did not redirect resident from wandering into bedrooms.
- Staff did not answer the facility door for visitors.

INVESTIGATION FINDINGS:

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On 9/14/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver investigation findings. LPA met with Assistant Executive Director (AED) Allison Lopez and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation relevant to the allegation listed above such as residents’ physician’s report, emergency contact, appraisals, and assessments.

Continue on page LIC9099-C.

Unsubstantiated

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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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 59-AS-20230510083840

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOW OAKS OF ROSEVILLE	FACILITY NUMBER: 317005900
	VISIT DATE: 09/14/2023

NARRATIVE

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Allegation- Staff did not provide incontinence care in a timely manner. – Unsubstantiated.

The Department conducted extensive records review and interviewed a total of four (4) facility staff. The Department reviewed residents’ physician's reports, level of care assessments. and appraisals. Interview stated gathered from caregivers indicate care was provided as stated. Interview statement from staff (S1) indicated, there are approximately 15 residents in Memory Care Unit (The Villa) and about 6 residents are incontinence. There are 2 caregivers working the AM and PM shift. The NOC shift consist of 1 caregiver. S1 stated S1 has not observed any residents in care left in soil and feces. Staff are providing incontinence care in a timely manner. Interview statement received from S2 and S3 were consistent with S1. S2 indicated if residents in care needs incontinence care staff would regularly check on that resident. S3 indicated staff would conduct rounds on residents that needs incontinence care every 15 minutes. The Department is unable to find and or meet the preponderance, per policy. The allegation of facility staff did not provide incontinence care in a timely manner is therefore unsubstantiated.

Allegation - Staff did not attend to resident who was vomiting in a timely manner. – Unsubstantiated.

The Department interviewed a total of four (4) facility staff. Interview statement received from AED indicated, R2 and R3 are roommates. R3 thought R2 was vomiting and went to notify staff. Staff went to check on R2 and did not observe R2 vomiting. R2 and R3 has Dementia. The Department requested for an incident report. AED stated the incident did not occur, so the facility did not generate an incident report. Interview with staff (S1 and S3) indicated that they do not have any knowledge of the incident. Interview statement received from S2 indicated, R2 is high functioning and told staff that R2 was not vomiting and did not need any assistance. R2 is able to pull cord for help and able to communicate needs.

Allegation - Staff did not redirect resident from wandering into bedrooms. – Unsubstantiated.

According to complainant, a male resident had wandered into a female resident’s room in underwear and there were no staff to redirect resident. Interview statement received from S1 indicated, S1 has not observed any residents wandering into other resident’s room. There are residents who wander around the hallways and common areas of the memory care unit. S1 indicated memory care residents exhibit wandering behaviors and needs prompting. Interview statement received from S2 and S3 indicated, they have no knowledge about the incident and which residents are involved. S2 indicated there are not a lot of male residents that wears underwear at the facility. Most residents do wear briefs.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230510083840

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOW OAKS OF ROSEVILLE	FACILITY NUMBER: 317005900
	VISIT DATE: 09/14/2023

NARRATIVE

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Allegation - Staff did not answer the facility door for visitors. – Unsubstantiated.

The Department conducted interviews with a total of four (4) facility staff. The memory care unit consist of two buildings that are connected via courtyard. The Villa is located on the side of the building and has its own entrance. According to AED, all visitors are to sign in at the front entrance and can be let into the memory care unit. If visitors head straight to the Villa and rings the doorbell staff would open the door. AED does not have any knowledge how long visitor was waiting for staff to open the door. Interview statement received from S1 indicated, it takes about 20 seconds for staff to answer the facility door for visitors, but it depends if staff are assisting the residents in care and may take a little longer but less than 5 minutes. Interview received from S2 indicated, there are two staff working in the Villa. If staff is assisting a resident there should be another staff on the floor. If both staff are assisting residents it would take longer for staff to open the door for visitors until staff knows it's safe to leave resident. Interviews gathered from S3 is consistent with S2.

The Department finds the allegations to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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