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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:46:15 PM


Document Has Been Signed on 09/17/2024 05:46 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: DATE:
09/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Charles HowardTIME COMPLETED:
06:00 PM
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On 9/17/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Generations Program Director (GPD), Charles Howard and Regional Clinical Specialist, Yvonne Williams .

On 9/16/24, the department received an incident report for R1 leaving the facility unassisted on 9/7/24. The incident report stated that staff was alerted to the back gate alarm. Staff looked inside for R1 while others searched outside. R1 was found unharmed by caregivers, "10 minutes" from the facility. R1 refused to return to return to the community until encouraged by responding local law enforcement.
LPA toured the facility with GPD to view where R1 was able to exit the property. Alarms from the exit door from the facility (near Rm 180 of the Lodge memory care) and the exit gate from the adjacent courtyard were operational. Though diagnosed with MCI at the time, R1 is in memory care.
Interview with GPD found that R1 is known to have exit seeking behavior and to experience sundowning. R1 was staffed with a 1:1 caregiver from a staffing agency until shortly before the incident at approximately 6:30 PM.
In addition to staff monitoring of residents, door alarms are monitored at the front desk for reception to alert caregivers to clear alarms. However, records reviewed found on 9/7/24, the front desk was only monitored until 5 PM.
3 caregivers were scheduled to work at the time. One of the 3 had just left on lunch break. Staff in the community were in the kitchen area opposite where R1 exited the building.
As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. 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: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 09/17/2024 05:46 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: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
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 will submit a plan for supervision, staffing and training plan for restidents in memory care by the POCdate of 9/18/24.
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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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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