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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: 108CENSUS: 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
NARRATIVE
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
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


Created By: Kevin Mknelly On 11/06/2024 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
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 ... safety ...needs as identified in his/her current appraisal. This requirement was
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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.
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not met based on records and interviews that found adequate number of staff were not present to implement R2's identified care need. This posed an immediate risk to R2.
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This POC is due by 11/7/24.

Civil Penalties Applied.
Type A
11/08/2024
Section Cited
CCR87465

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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care ... The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-
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Staff found to have made the error have been removed from medication duties.
Licensee agrees to retrain all mediation technicians on the 7 R's of med administration, implement procedures for med techs reviewing previous shift docuentation for all meds that they pass,
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administered medications as needed. This requirement was not met based on records and interviews which found care staff were not compliant with assisting R1 correctly with medications. This posed an immediate risk to R1.
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and procedures for reporting/ responding medication errors/ inconsistencies to managers before the medication is administered, when applicable.
Licensee will submit the plan for training and procedures to be reviewed to CCL by the POC date of 11/8/24
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 Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
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


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