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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:01:29 PM

Document Has Been Signed on 11/06/2024 03:01 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/
DIRECTOR:
JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 108TOTAL ENROLLED CHILDREN: 0CENSUS: 74DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Jessica SandersTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 11/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Director, Jessica Sanders.

On 11/5/24 the Regional Office received incident reports for the following incidents:
Incident 1- On 10/30/24, medication technician, S1, notified managers that a medication documentation irregularity was found. The incident involved R1 who was supposed to receive a daily full tab of a controlled medication. The incident report noted that R1 was documented to have received a half tab of the medication instead of the prescribed full tab 10/7/24- 10/30/24. R1 was unharmed as a result. R1's physician was notified and corrective action was taken with the three staff who had made the error. LPA reviewed records and conducted interviews where it was found that staff deviated from facility policies and did not follow medication training that resulted in R1 not receiving medication assistance for medications as prescribed.

Incident 2- On 11/3/24, at approximately 1:30 PM, staff discovered R2 to be missing. R2 has a known history of attempts to leave the memory care without physician's recommended assistance when leaving. The care plan in place was for staff to maintain "eyes on" for R2 during waking hours. In this incident it is unknown how R2 left unaccompanied. LPA conducted interviews with R2, Administrator and 2 caregivers that were present on 11/3/24. Interviews found that while staff were aware of R2's exit seeking behaviors, there was not a concrete plan for how the staff present would maintain eyes on R2.
On 11/3/24, R2 was found by local police a short way from the facility and was returned unharmed.
This is the second such event for R2. It is found that there was not an adequate number of direct care staff to support each resident’s safety needs as identified in his/her current appraisal. The facility has since added additional care staff to PM shifts.
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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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
VISIT DATE: 11/06/2024
NARRATIVE
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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.

The citation for insufficient staff for dementia care is the third within 12 months. Civil Penalties are applied.

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: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 03:01 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: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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 ... safety ...needs as identified in his/her current appraisal. This requirement was
Deficient Practice Statement
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POC Due Date: 11/07/2024
Plan of Correction
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Licensee agrees to submit a concrete plan for how staff are to maintain eyes on R2, including contingency plans for when other resident needs may interupt the observation of R2 and will include a daily/ every shift schedule for which staff are responsible for the monitoring of R2.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
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