<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:41:26 PM

Document Has Been Signed on 01/22/2025 04:41 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: 70DATE:
01/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Jessica SandersTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Administrator .

On 11/6/24, the department received a Death Notification for R1's passing on 11/4/24 while hospitalized. The notification stated that R1 was sent to the hospital on 11/1/24, approximately 9 AM, for a "declining baseline". R1's death was not expected and R1 was not on hospice care.



On 11/14/24, the Department conducted an initial case management visit regarding the death of R1.

LPA requested and reviewed R1 records prior to the 11/14/24 visit. LPA received additional records on 11/14/24 as well conducting interviews of resident care director, memory care director and three caregivers.


The department also received and reviewed medical records and the death certificate for R1.

At this time, the department finds that resident exhibited changes of condition and had not taken several prescribed medications for three days prior to R1’s 11/1/24 hospitalization. The changes and missed medication were not reported to R1’s physician and assistance was not provided to R1 for medical care.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 01/22/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/22/2025 04:41 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 01/22/2025 at 12:20 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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2025
Section Cited
CCR
87466

1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning …When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed,
1
2
3
4
5
6
7
Licensee will submit a plan for a review and training of accountable staff for reporting, recording and contacting medical care for changes in conditions- training to be completed within seven days.
8
9
10
11
12
13
14
the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician…
This requirement was not met based on records and interviews which showed a change of condition not brought to the physician’s attention. This posed an immediate risk to the resident.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3