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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:31:07 PM


Document Has Been Signed on 05/03/2024 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 80DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jessica SandersTIME COMPLETED:
02:30 PM
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On 5/3/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director (ED), Jessica Sanders.

On 4/24/24, the department received an incident report regarding an incident involving R1 that occurred on 4/20/24. The report stated that at approximately 3:55 on 4/20/24, R1 exited memory care and then was able to leave the property unassisted. After a search of the property was conducted, local police were notified. Police located R1 several blocks from the facility. R1 was returned unharmed to the facility.

In interview with the ED,ED stated an internal investigation was unable to identify when and how R1 exited the facility. Tests of the facility's delayed egress alarms found them to be functioning properly. However, the exit doors were known to at times not close all the way. Staff were to regularly check that doors were closed. There were 2 caregivers on duty at the time with 12 residents. R1 was last seen at approximately 3:15 PM, having visited the Generations Program Director's office in memory care.

R1's LIC 602 and appraisal identifies R1 as having dementia, exit seeking behavior and is unable to leave unassisted.

An inspection of The Villa area where R1 resided, found an exit to the parking lot one door down from R1's room and a main exit from the lobby of The Villa. The lobby from The Villa is not staffed with a receptionist. Care staff greet and allow entry to visitors.

As a result of this inspection, the following deficiencies were cited on 809-D.
Report reviewed. Copy of report and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2024 02:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2024
Section Cited
CCR
87705(c)(4)

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current appraisal
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Licensee has repaired doors to insure they fully close when exited.

Licensee will submit records of staff training having been conducted as a result of this incident by the POC date of 5/6/24.
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 health care needs as identified in his/her.. This requirement was not met based on reports and statements. This posed an immediate risk to R1's health and safety.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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